| Graceland Psychiatric And Neuromodulation Center Pllc | |
|
2411 Ne Loop 410 Ste 114 San Antonio TX 78217-6600 | |
| (210) 868-5801 | |
| (726) 201-1558 |
| Full Name | Graceland Psychiatric And Neuromodulation Center Pllc |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 2411 Ne Loop 410 Ste 114, San Antonio, Texas |
| Authorized Official Name and Position | Femi Popoola (MEDICAL DIRECTOR/OWNER) |
| Authorized Official Contact | 2108685801 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Graceland Psychiatric And Neuromodulation Center Pllc 2411 Ne Loop 410 Ste 114 San Antonio TX 78217-6600 Ph: (210) 868-5801 | Graceland Psychiatric And Neuromodulation Center Pllc 2411 Ne Loop 410 Ste 114 San Antonio TX 78217-6600 Ph: (210) 868-5801 |
| NPI Number | 1518548262 |
|---|---|
| Provider Enumeration Date | 04/15/2021 |
| Last Update Date | 09/19/2024 |
| Certification Date | 09/18/2024 |
| Medicare PECOS PAC ID | 4789081662 |
|---|---|
| Medicare Enrollment ID | O20210920001551 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1518548262 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| Provider Name | Taiwo Okubanjo |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1285192963 PECOS PAC ID: 4880925494 Enrollment ID: I20191014000990 |
| Provider Name | Jordan Nichole Davis |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245864396 PECOS PAC ID: 6204259757 Enrollment ID: I20200701000441 |
| Provider Name | Femi Popoola |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1417307380 PECOS PAC ID: 9638462922 Enrollment ID: I20210929003277 |
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