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General NPI Number Information
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NPI Number | 1073202115
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Entity Type | Organization
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Legal Business Name | BY HIS GRACE PRIMARY CARE, LLC
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Dates
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Enumeration Date | 05/04/2023
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Last Update Date | 05/04/2023
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Provider Practice Location Address
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Address Line | 806 GLOVER AVE STE A
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City | ENTERPRISE
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State | AL
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Zip | 36330-2018
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Country | US
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Telephone | 334-475-2680
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Fax | 334-475-2681
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Provider Business Mailing Address
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Address Line | 806 GLOVER AVE STE A
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City | ENTERPRISE
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State | AL
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Zip | 36330-2018
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Country | US
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Telephone | 334-475-2680
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Fax | 334-475-2681
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Authorized Official
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Title or Position | CRNO, CEO
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Name | SAMANTHA PICKETT
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Credential | CRNP
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Telephone | 334-806-9233
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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