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General NPI Number Information
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NPI Number | 1104107192
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Entity Type | Organization
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Legal Business Name | GRACE PLACE FOR WOMEN, INCORPORATED
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Dates
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Enumeration Date | 09/02/2011
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Last Update Date | 05/23/2012
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Provider Practice Location Address
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Address Line | 4801 N BUTLER AVE STE 3102
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City | FARMINGTON
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State | NM
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Zip | 87401-0815
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Country | US
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Telephone | 505-327-4747
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Fax | 505-327-2025
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Provider Business Mailing Address
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Address Line | PO BOX 2256
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City | FARMINGTON
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State | NM
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Zip | 87499-2256
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Country | US
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Telephone | 505-327-4747
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Fax | 505-327-2025
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Authorized Official
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Title or Position | CEO
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Name | DEBORAH JOSLIN
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Credential |
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Telephone | 505-327-4747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | MD2010-0578
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA2008-0053
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | MD2010-0229
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License Number State | NM
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