=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821645896
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE MOUNTAIN MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2019
-----------------------------------------------------
Last Update Date | 11/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 LEE AVE STE 101
-----------------------------------------------------
City | PIKEVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41501-2047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-727-5296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1235 SALTLICK RD
-----------------------------------------------------
City | HUEYSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41640-6653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-226-8677
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | TONYA RENEE SHEPHERD HATFIELD
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 606-226-8677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------