Healthcare Provider Details

I. General information

NPI: 1174669568
Provider Name (Legal Business Name): GRACE HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 E MARKET ST
MC LEANSBORO IL
62859-1317
US

IV. Provider business mailing address

104 E MARKET ST
MC LEANSBORO IL
62859-1317
US

V. Phone/Fax

Practice location:
  • Phone: 618-643-3051
  • Fax: 618-643-3164
Mailing address:
  • Phone: 618-643-3051
  • Fax: 618-643-3164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateIL

VIII. Authorized Official

Name: MRS. RENE L TROTTER
Title or Position: OFFICER
Credential: FNP
Phone: 618-643-3051