MEDICARE: GRACE FAMILY MEDICAL CENTER

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

General Provider Information

NPI Number	:	1598896961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE FAMILY MEDICAL CENTER

Provider Business Mailing Address
First Line	:	24438 PLANK RD
Second Line	:
City	:	SLAUGHTER
State	:	LA
Zip	:	70777-9701
Country	:	US
Telephone Number	:	225-381-6765
Fax Number	:	225-381-6767

Provider Business Practice Location Address
First Line	:	3849 NORTH BLVD
Second Line	:	SUITE 100
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-3854
Country	:	US
Telephone Number	:	225-381-6765
Fax Number	:	225-381-6767

Authorized Official
Title or Position	:	PHYSICIAN ASSISTANT
Name	:	MRS. ALENCIA CLAYTON ELLIS
Credential	:	PA
Telephone Number	:	225-381-6765

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	08/22/2020

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