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General NPI Number Information
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NPI Number | 1376190025
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Entity Type | Organization
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Legal Business Name | C&G'S GRACE PLACE LLC
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Dates
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Enumeration Date | 08/19/2019
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Last Update Date | 08/19/2019
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Provider Practice Location Address
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Address Line | 6763 KRENSON OAKS CIR
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City | LAKELAND
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State | FL
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Zip | 33810-2157
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Country | US
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Telephone | 813-468-5303
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Fax | 863-578-3659
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Provider Business Mailing Address
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Address Line | 6763 KRENSON OAKS CIR
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City | LAKELAND
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State | FL
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Zip | 33810-2157
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Country | US
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Telephone | 813-468-5303
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Fax | 863-578-3659
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Authorized Official
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Title or Position | OWNER
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Name | LATESHA GASKIKNS
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Credential |
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Telephone | 813-468-5303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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