{
"Npi": {
"NPI": "1740990886",
"EntityType": "Organization",
"ReplacementNPI": null,
"EIN": null,
"IsSoleProprietor": null,
"IsOrgSubpart": "N",
"ParentOrgLBN": null,
"ParentOrgTIN": null,
"OrgName": "GRACE INTERNAL MEDICINE, LLC",
"LastName": null,
"FirstName": null,
"MiddleName": null,
"NamePrefix": null,
"NameSuffix": null,
"Credential": null,
"OtherOrgName": null,
"OtherOrgNameTypeCode": null,
"OtherLastName": null,
"OtherFirstName": null,
"OtherMiddleName": null,
"OtherNamePrefix": null,
"OtherNameSuffix": null,
"OtherCredential": null,
"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "102 MEDICAL CENTER DR STE F",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "PRATTVILLE",
"MailingAddressStateName": "AL",
"MailingAddressPostalCode": "36066-7286",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "334-568-2335",
"MailingAddressFaxNumber": "334-568-2336",
"FirstLinePracticeLocationAddress": "102 MEDICAL CENTER DR STE F",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "PRATTVILLE",
"PracticeLocationAddressStateName": "AL",
"PracticeLocationAddressPostalCode": "36066-7286",
"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "334-568-2335",
"PracticeLocationAddressFaxNumber": "334-380-3567",
"EnumerationDate": "11/30/2022",
"LastUpdateDate": "06/12/2023",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "FAISON",
"AuthorizedOfficialFirstName": "VANOSIA",
"AuthorizedOfficialMiddleName": "SHABLEE",
"AuthorizedOfficialTitle": "CEO",
"AuthorizedOfficialNamePrefix": "DR.",
"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": "MD",
"AuthorizedOfficialTelephoneNumber": "334-568-2335",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "261QP2300X",
"TaxonomyName": "Primary Care Clinic/Center",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}