MEDICARE: LOVING GRACE PCH

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	261QM0850X	Adult Mental Health Clinic/Center		GA

General Provider Information

NPI Number	:	1972774842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOVING GRACE PCH

Provider Business Mailing Address
First Line	:	1236 12TH ST
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30901-3238
Country	:	US
Telephone Number	:	706-364-4379
Fax Number	:	706-364-4378

Provider Business Practice Location Address
First Line	:	1213 WOOD VALLEY RD
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-2327
Country	:	US
Telephone Number	:	706-738-9032
Fax Number	:	706-738-9032

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TONDA BOOKER
Credential	:
Telephone Number	:	706-831-4472

Provider Enumeration Date	:	03/18/2008
Last Update Date	:	03/18/2008

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