=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295290963
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE HEALTH CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2019
-----------------------------------------------------
Last Update Date | 06/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 CORPORATE SQUARE DR STE A
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-3151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-259-4854
-----------------------------------------------------
Fax | 855-807-4750
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 CORPORATE SQUARE DR STE A
-----------------------------------------------------
City | SLIDELL
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70458-3151
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-259-4854
-----------------------------------------------------
Fax | 855-807-4750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINIC ADMINISTRATOR
-----------------------------------------------------
Name | BIANCA D JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 985-259-4854
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------