MEDICARE: GRACE WELLNESS CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	261Q00000X	Clinic/Center
2	261QP2300X	Primary Care Clinic/Center
3	363LP2300X	Primary Care Nurse Practitioner
4	207Q00000X	Family Medicine Physician

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	:	1497371108
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	2504 ACORN STREET
Second Line	:	STE A
City	:	FORT PIERCE
State	:	FL
Zip	:	34947
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2504 ACORN ST STE A
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4746
Country	:	US
Telephone Number	:	772-837-7800
Fax Number	:	772-837-7801

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	BARBIE BRUNET
Credential	:	ARNP
Telephone Number	:	772-837-7800

Provider Enumeration Date	:	06/18/2020
Last Update Date	:	03/16/2022

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