Healthcare Provider Details

I. General information

NPI: 1881487197
Provider Name (Legal Business Name): SPLENDID GRACE PRIME
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2025
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 S HURON RD APT 10
KAWKAWLIN MI
48631-9492
US

IV. Provider business mailing address

1287 S HURON RD APT 10
KAWKAWLIN MI
48631-9492
US

V. Phone/Fax

Practice location:
  • Phone: 531-346-6555
  • Fax: 999-999-9999
Mailing address:
  • Phone: 531-346-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: