Healthcare Provider Details

I. General information

NPI: 1497426167
Provider Name (Legal Business Name): GRACE POPHAM HOBBES MS, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRACE HIGGINS POPHAM

II. Dates (important events)

Enumeration Date: 09/23/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ROME AVE
PROVIDENCE RI
02908-1227
US

IV. Provider business mailing address

1 CUNNINGHAM SQ
PROVIDENCE RI
02918-7001
US

V. Phone/Fax

Practice location:
  • Phone: 401-499-1455
  • Fax:
Mailing address:
  • Phone: 401-865-1752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT00377
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: