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General NPI Number Information
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NPI Number | 1104370915
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Entity Type | Organization
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Legal Business Name | GRACE MEDICAL CONSULT
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Dates
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Enumeration Date | 08/09/2016
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Last Update Date | 08/09/2016
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Provider Practice Location Address
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Address Line | 40 UNION AVE 3RD FL. STE 301
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City | IRVINGTON
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State | NJ
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Zip | 07111-3277
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Country | US
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Telephone | 973-996-2170
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Fax |
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Provider Business Mailing Address
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Address Line | 40 UNION AVE 3RD FL. STE 301
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City | IRVINGTON
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State | NJ
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Zip | 07111-3277
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Country | US
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Telephone | 973-996-2170
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | MR. ADEWALE ADEFOWOJU
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Credential | MSN, APN, PMHNP-BC
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Telephone | 908-693-5036
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 26NJ00196200
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License Number State | NJ
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