=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235486531
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE COMMUNITY HEALTH CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2012
-----------------------------------------------------
Last Update Date | 06/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5923 HIGHWAY 80
-----------------------------------------------------
City | WOOTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41776-8840
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-526-9005
-----------------------------------------------------
Fax | 606-526-8606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5923 HWY 80
-----------------------------------------------------
City | WOOTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41776-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-526-9005
-----------------------------------------------------
Fax | 606-526-8606
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | C.E.O.
-----------------------------------------------------
Name | MICHAEL W. STANLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 606-526-9005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 700188
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------