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General NPI Number Information
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NPI Number | 1417308966
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Entity Type | Organization
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Legal Business Name | GOOD GRACE PROVIDER SERVICE
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Dates
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Enumeration Date | 06/27/2016
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Last Update Date | 06/27/2016
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Provider Practice Location Address
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Address Line | 15155 RICHMOND AVE APT 833
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City | HOUSTON
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State | TX
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Zip | 77082-1637
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Country | US
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Telephone | 832-890-5451
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Fax | 832-210-2210
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Provider Business Mailing Address
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Address Line | 15155 RICHMOND AVE APT 833
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City | HOUSTON
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State | TX
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Zip | 77082
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Country | US
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Telephone | 832-890-5451
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Fax | 832-210-2210
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Authorized Official
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Title or Position | OWNER
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Name | CYNTHIA MARIA GONZALEZ
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Credential | CMG
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Telephone | 832-890-5451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251T00000X
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Taxonomy Name | PACE Provider Organization
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License Number |
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License Number State |
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