Provider Demographics
NPI:1447307384
Name:GRACE PEDIATRIC CLINIC, P.A.
Entity type:Organization
Organization Name:GRACE PEDIATRIC CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:TOKUNBOH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:709-409-3000
Mailing Address - Street 1:2401 TUCKASEEGEE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4058
Mailing Address - Country:US
Mailing Address - Phone:704-409-3000
Mailing Address - Fax:704-409-2382
Practice Address - Street 1:2401 TUCKASEEGEE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-4058
Practice Address - Country:US
Practice Address - Phone:704-409-3000
Practice Address - Fax:704-409-2382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800405208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891359NMedicaid