=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366769408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE & MERCY HEALTH CLINIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2010
-----------------------------------------------------
Last Update Date | 10/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 N MAIN BOX 391
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75152-9538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-449-3555
-----------------------------------------------------
Fax | 972-449-3344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 110 N MAIN ST P.O. BOX 391
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75152-9538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-449-3555
-----------------------------------------------------
Fax | 972-449-3344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. ENOLA NELSON
-----------------------------------------------------
Credential | PA PHD
-----------------------------------------------------
Telephone | 972-449-3555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | F0194
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------