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General NPI Number Information
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NPI Number | 1740990886
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Entity Type | Organization
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Legal Business Name | GRACE INTERNAL MEDICINE, LLC
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Dates
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Enumeration Date | 11/30/2022
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Last Update Date | 06/12/2023
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Provider Practice Location Address
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Address Line | 102 MEDICAL CENTER DR STE F
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City | PRATTVILLE
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State | AL
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Zip | 36066-7286
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Country | US
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Telephone | 334-568-2335
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Fax | 334-380-3567
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Provider Business Mailing Address
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Address Line | 102 MEDICAL CENTER DR STE F
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City | PRATTVILLE
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State | AL
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Zip | 36066-7286
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Country | US
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Telephone | 334-568-2335
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Fax | 334-568-2336
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Authorized Official
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Title or Position | CEO
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Name | DR. VANOSIA SHABLEE FAISON
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Credential | MD
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Telephone | 334-568-2335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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