NPIMap

Organization Active NPI

Grace Pediatrics PL

  • Rural Health Clinic/Center
  • Fort White, FL
National Provider Identifier
1326885294
Registry record updated Jul 9, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
GRACE PEDIATRICS PL
Practice address
238 SW Cullen Ave
Fort White, FL 32038-3536
Phone
(386) 243-8474
NPI assigned
Jul 9, 2024
Last updated
Jul 9, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 9, 2024

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

Authorized official

Name
Colleen A ThompsonNPI 1922007475
Title
Aprn, Owner
Phone
(386) 243-8474

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

238 SW Cullen Ave
Fort White, FL 32038-3536

Mailing address

4196 W US Highway 90 Ste 105
Lake City, FL 32055-8834
Phone (386) 243-8474

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240730000554 FL Part A Provider - Rural Health Clinic 0547403545 Practice locations: Fort White, FL

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1326885294. Details of each certification follow.

Rural health clinic certification: CCN 683850

Legal name
GRACE PEDIATRICS PL
Organization structure
LLCProprietary
Incorporated
May 1, 2012 in FL
Enrollment address
238 SW Cullen Ave
Fort White, FL 32038-3536

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Grace Pediatrics2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Colleen a Thompson Individual 5% Or Greater Direct Ownership Interest May 1, 2012 100%
W-2 Managing EmployeePresident May 1, 2012 100%
Operational/Managerial Control May 1, 2012

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1720483200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720483200000",
    "number": "1326885294",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4196 W US HIGHWAY 90 STE 105",
            "city": "LAKE CITY",
            "state": "FL",
            "postal_code": "320558834",
            "telephone_number": "386-243-8474",
            "fax_number": "386-438-5945"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "238 SW CULLEN AVE",
            "city": "FORT WHITE",
            "state": "FL",
            "postal_code": "320383536",
            "telephone_number": "386-243-8474"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "GRACE PEDIATRICS PL",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-07-09",
        "last_updated": "2024-07-09",
        "certification_date": "2024-07-09",
        "status": "A",
        "authorized_official_last_name": "THOMPSON",
        "authorized_official_first_name": "COLLEEN",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "APRN, OWNER",
        "authorized_official_telephone_number": "386-243-8474"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort White, FL

Sources for this page

Verify at the official NPI Registry.