Healthcare Provider Details

I. General information

NPI: 1043609134
Provider Name (Legal Business Name): SOUTHERN GRACE HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2015
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

364 RACETRACK RD
MCDONOUGH GA
30252-1022
US

IV. Provider business mailing address

364 RACETRACK RD
MCDONOUGH GA
30252-1022
US

V. Phone/Fax

Practice location:
  • Phone: 678-432-8811
  • Fax: 678-432-8821
Mailing address:
  • Phone: 678-432-8811
  • Fax: 678-432-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number64068
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: AUBREY KEKIWI
Title or Position: CEO
Credential:
Phone: 678-432-8811