MEDICARE: GRACE WEEKEND CLINIC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	108529	MO

General Provider Information

NPI Number	:	1225125461
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE WEEKEND CLINIC, INC

Provider Business Mailing Address
First Line	:	417 PARK LN
Second Line	:
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-1550
Country	:	US
Telephone Number	:	660-646-3400
Fax Number	:	660-646-3410

Provider Business Practice Location Address
First Line	:	417 PARK LN
Second Line	:
City	:	CHILLICOTHEE
State	:	MO
Zip	:	64601-1550
Country	:	US
Telephone Number	:	660-646-3400
Fax Number	:	660-646-3410

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. DEA DENISE CAMPBELL
Credential	:	D.O.
Telephone Number	:	660-646-3400

Provider Enumeration Date	:	10/09/2006
Last Update Date	:	08/09/2007

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