MEDICARE: GRACE FAMILY MEDICINE, LLC

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	261QP2300X	Primary Care Clinic/Center
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1831712801
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE FAMILY MEDICINE, LLC

Provider Business Mailing Address
First Line	:	11191 GRANDVIEW MNR
Second Line	:
City	:	WELLINGTON
State	:	FL
Zip	:	33414-8840
Country	:	US
Telephone Number	:	561-317-2389
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 LAKE WORTH RD STE 211
Second Line	:
City	:	GREENACRES
State	:	FL
Zip	:	33463-3275
Country	:	US
Telephone Number	:	561-331-5155
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	CARLOS POVEDA
Credential	:	MHA
Telephone Number	:	561-317-2389

Provider Enumeration Date	:	05/25/2020
Last Update Date	:	05/04/2025

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