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General NPI Number Information
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NPI Number | 1972774842
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Entity Type | Organization
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Legal Business Name | LOVING GRACE PCH
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Dates
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Enumeration Date | 03/18/2008
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Last Update Date | 03/18/2008
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Provider Practice Location Address
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Address Line | 1213 WOOD VALLEY RD
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City | AUGUSTA
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State | GA
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Zip | 30909-2327
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Country | US
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Telephone | 706-738-9032
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Fax | 706-738-9032
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Provider Business Mailing Address
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Address Line | 1236 12TH ST
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City | AUGUSTA
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State | GA
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Zip | 30901-3238
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Country | US
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Telephone | 706-364-4379
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Fax | 706-364-4378
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Authorized Official
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Title or Position | OWNER
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Name | MR. TONDA BOOKER
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Credential |
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Telephone | 706-831-4472
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State | GA
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