Healthcare Provider Details

I. General information

NPI: 1225125461
Provider Name (Legal Business Name): GRACE WEEKEND CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 PARK LN
CHILLICOTHEE MO
64601-1550
US

IV. Provider business mailing address

417 PARK LN
CHILLICOTHEE MO
64601-1550
US

V. Phone/Fax

Practice location:
  • Phone: 660-646-3400
  • Fax: 660-646-3410
Mailing address:
  • Phone: 660-646-3400
  • Fax: 660-646-3410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number108529
License Number StateMO

VIII. Authorized Official

Name: DR. DEA DENISE CAMPBELL
Title or Position: OWNER/OPERATOR
Credential: D.O.
Phone: 660-646-3400