Healthcare Provider Details

I. General information

NPI: 1649149238
Provider Name (Legal Business Name): EXCELSIOR GRACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2025
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 W 4TH ST
PLAINFIELD NJ
07063-1372
US

IV. Provider business mailing address

959 W 4TH ST
PLAINFIELD NJ
07063-1372
US

V. Phone/Fax

Practice location:
  • Phone: 347-302-1212
  • Fax:
Mailing address:
  • Phone: 347-302-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: OLUWABUNMI OMOTAYO
Title or Position: OWNER
Credential: APN
Phone: 347-302-1212