Provider Demographics
NPI:1447374780
Name:EKONG, GRACE EYO
Entity type:Individual
Prefix:MS
First Name:GRACE
Middle Name:EYO
Last Name:EKONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 N. SHERIDAN RD EAST
Mailing Address - Street 2:EAST POINT BUILDING, SUITE 9B
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-2880
Mailing Address - Country:US
Mailing Address - Phone:773-973-1236
Mailing Address - Fax:773-974-6157
Practice Address - Street 1:6101 N SHERIDAN RD EAST
Practice Address - Street 2:SUITE 9B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-2880
Practice Address - Country:US
Practice Address - Phone:773-973-1236
Practice Address - Fax:773-974-6157
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1168939332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01632432OtherMEDICAL SUPPLIES & DME
IL364435286-001Medicaid
IL01632432OtherMEDICAL SUPPLIES & DME