NPIMap

Organization Active NPI

Grace Health Clinic

  • Family Medicine Physician
  • Slidell, LA
National Provider Identifier
1295290963
Registry record updated Jun 17, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
GRACE HEALTH CLINIC
Practice address
1415 Corporate Square Dr Ste a
Slidell, LA 70458-3151
Phone
(985) 259-4854
Fax
(855) 807-4750
NPI assigned
Feb 6, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 17, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bianca D Jackson
Title
Clinic Administrator
Phone
(985) 259-4854

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

1415 Corporate Square Dr Ste a
Slidell, LA 70458-3151

Mailing address

1415 Corporate Square Dr Ste a
Slidell, LA 70458-3151
Phone (985) 259-4854

Other practice location 1

1425 Fremaux Ave
Slidell, LA 70458-3150
Phone (601) 287-4038

Other identifiers 2

IdentifierTypeStateIssuer
05427361MedicaidMS
2427806MedicaidLA

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20190719000668 LA Part B Supplier - Clinic/Group Practice 2668708272 Receives reassigned benefits from 4 practitioners
Practice locations: Slidell, LA

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D2158646Grace Health Clinic, LLC1415 Corporate Square Drive, Suite a, Slidell, LA 70458Certificate of waiverOct 21, 2027

National Provider Directory

National Provider Directory

Locations

1425 Fremaux Ave
Slidell, LA 70458
Phone (601) 287-4038

1415 Corporate Square Dr
#A
Slidell, LA 70458

Interoperability endpoints

  • FHIR API: https://api.platform.athenahealth.com/18812/brand/1/csg/1/fhir/r4

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1549411200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1623888000000",
    "number": "1295290963",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1415 CORPORATE SQUARE DR STE A",
            "city": "SLIDELL",
            "state": "LA",
            "postal_code": "704583151",
            "telephone_number": "985-259-4854",
            "fax_number": "855-807-4750"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1415 CORPORATE SQUARE DR STE A",
            "city": "SLIDELL",
            "state": "LA",
            "postal_code": "704583151",
            "telephone_number": "985-259-4854",
            "fax_number": "855-807-4750"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1425 Fremaux Ave",
            "address_purpose": "LOCATION",
            "city": "Slidell",
            "state": "LA",
            "postal_code": "704583150",
            "country_code": "US",
            "telephone_number": "601-287-4038",
            "fax_number": "855-807-4750",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "GRACE HEALTH CLINIC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-02-06",
        "last_updated": "2021-06-17",
        "certification_date": "2021-06-17",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "BIANCA",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "CLINIC ADMINISTRATOR",
        "authorized_official_telephone_number": "985-259-4854"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05427361",
            "state": "MS"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2427806",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Slidell, LA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.