=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881217685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE MEDICAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2020
-----------------------------------------------------
Last Update Date | 09/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 422 GRAND ST # 9-10
-----------------------------------------------------
City | HOBOKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07030-2727
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-693-5036
-----------------------------------------------------
Fax | 862-849-2319
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1379 BROOKFALL AVE
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-7013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-693-5036
-----------------------------------------------------
Fax | 862-849-2319
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. ADEWALE ADEFOWOJU
-----------------------------------------------------
Credential | DNP, APN, PMHNP-BC
-----------------------------------------------------
Telephone | 908-693-5036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------