Healthcare Provider Details

I. General information

NPI: 1023886835
Provider Name (Legal Business Name): GRACE GALLOWAY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2023
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1781B S MAIN ST
LAURINBURG NC
28352-5407
US

IV. Provider business mailing address

217 PALASIDE DR NE
CONCORD NC
28025-3029
US

V. Phone/Fax

Practice location:
  • Phone: 910-506-4018
  • Fax: 980-294-1398
Mailing address:
  • Phone: 980-322-5447
  • Fax: 980-294-1398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: GRACE LIEM GALLOWAY
Title or Position: MANAGER
Credential: PHD
Phone: 980-322-5447