Healthcare Provider Details

I. General information

NPI: 1821645896
Provider Name (Legal Business Name): GRACE MOUNTAIN MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2019
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 LEE AVE STE 101
PIKEVILLE KY
41501-2047
US

IV. Provider business mailing address

1235 SALTLICK RD
HUEYSVILLE KY
41640-6653
US

V. Phone/Fax

Practice location:
  • Phone: 606-727-5296
  • Fax:
Mailing address:
  • Phone: 606-226-8677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: TONYA RENEE SHEPHERD HATFIELD
Title or Position: CO-OWNER
Credential: APRN
Phone: 606-226-8677