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General NPI Number Information
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NPI Number | 1073898631
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Entity Type | Organization
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Legal Business Name | HIS GRACE MEDICAL, LLC
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Dates
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Enumeration Date | 10/14/2011
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Last Update Date | 10/29/2012
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Provider Practice Location Address
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Address Line | 1635 W DIVISION ST SUITE A
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City | ARLINGTON
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State | TX
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Zip | 76012-3810
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Country | US
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Telephone | 817-704-8081
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 153202
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City | ARLINGTON
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State | TX
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Zip | 76015-9202
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PARTNER
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Name | DR. EBENEZER ALABI
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Credential |
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Telephone | 817-704-8081
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 45D1091543
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License Number State | TX
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