MEDICARE: GRACE FAMILY CARE, PC

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	261QH0100X	Health Service Clinic/Center	N 97 00121	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457674269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE FAMILY CARE, PC

Provider Business Mailing Address
First Line	:	10616 METROMONT PKWY
Second Line	:	SUITE 104
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-7656
Country	:	US
Telephone Number	:	704-921-6659
Fax Number	:	704-921-6698

Provider Business Practice Location Address
First Line	:	10616 METROMONT PKWY
Second Line	:	SUITE 104
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-7657
Country	:	US
Telephone Number	:	704-921-6659
Fax Number	:	704-921-6698

Authorized Official
Title or Position	:	CEO
Name	:	GRACE C PAMINTUAN
Credential	:	M.D.
Telephone Number	:	704-921-6659

Provider Enumeration Date	:	03/08/2010
Last Update Date	:	03/08/2010

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