=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932795390
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BGRACEFUL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2020
-----------------------------------------------------
Last Update Date | 12/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 DOUG BAKER BLVD STE 107566
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-941-6099
-----------------------------------------------------
Fax | 205-303-3166
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1401 DOUG BAKER BLVD STE 107566
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35242-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-941-6099
-----------------------------------------------------
Fax | 205-303-3166
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NP
-----------------------------------------------------
Name | LATOYA M CARSTARPHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-941-6099
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------