Provider Demographics
NPI:1447835483
Name:OLIVER, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:OLIVER
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 1:6130 IRON ROCK ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77087-3228
Mailing Address - Country:US
Mailing Address - Phone:832-687-0486
Mailing Address - Fax:713-929-3572
Practice Address - Street 1:5831 LE CARPE PLANTATION CT
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-5373
Practice Address - Country:US
Practice Address - Phone:832-687-0486
Practice Address - Fax:713-929-3572
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX862043361Medicaid