Healthcare Provider Details

I. General information

NPI: 1447307384
Provider Name (Legal Business Name): GRACE PEDIATRIC CLINIC, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 TUCKASEEGEE RD
CHARLOTTE NC
28208-4058
US

IV. Provider business mailing address

2401 TUCKASEEGEE RD
CHARLOTTE NC
28208-4058
US

V. Phone/Fax

Practice location:
  • Phone: 704-409-3000
  • Fax: 704-409-2382
Mailing address:
  • Phone: 704-409-3000
  • Fax: 704-409-2382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9800405
License Number StateNC

VIII. Authorized Official

Name: DR. JULIUS TOKUNBOH
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 709-409-3000