Healthcare Provider Details

I. General information

NPI: 1972774842
Provider Name (Legal Business Name): LOVING GRACE PCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2008
Last Update Date: 03/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 WOOD VALLEY RD
AUGUSTA GA
30909-2327
US

IV. Provider business mailing address

1236 12TH ST
AUGUSTA GA
30901-3238
US

V. Phone/Fax

Practice location:
  • Phone: 706-738-9032
  • Fax: 706-738-9032
Mailing address:
  • Phone: 706-364-4379
  • Fax: 706-364-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. TONDA BOOKER
Title or Position: OWNER
Credential:
Phone: 706-831-4472