Healthcare Provider Details

I. General information

NPI: 1013336627
Provider Name (Legal Business Name): GRACE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 04/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 WORTH CIR SUITE 2
JOHNSON CITY TN
37601-4306
US

IV. Provider business mailing address

2 WORTH CIR SUITE 2
JOHNSON CITY TN
37601-4306
US

V. Phone/Fax

Practice location:
  • Phone: 423-283-4958
  • Fax: 423-283-7135
Mailing address:
  • Phone: 423-283-4958
  • Fax: 423-283-7135

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number11054
License Number StateTN

VIII. Authorized Official

Name: MR. GORDON E COBURN
Title or Position: OWNER
Credential: APRN-BC
Phone: 423-283-4958