Healthcare Provider Details

I. General information

NPI: 1831712801
Provider Name (Legal Business Name): GRACE FAMILY MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 05/04/2025
Certification Date: 05/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 LAKE WORTH RD STE 211
GREENACRES FL
33463-3275
US

IV. Provider business mailing address

11191 GRANDVIEW MNR
WELLINGTON FL
33414-8840
US

V. Phone/Fax

Practice location:
  • Phone: 561-331-5155
  • Fax:
Mailing address:
  • Phone: 561-317-2389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CARLOS POVEDA
Title or Position: MANAGER
Credential: MHA
Phone: 561-317-2389