MEDICARE: TRACEY CIVIL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251J00000X	Nursing Care Agency

General Provider Information

NPI Number	:	1053082180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEY CIVIL

Provider Business Mailing Address
First Line	:	2505 CLUB PL
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-8218
Country	:	US
Telephone Number	:	954-451-4116
Fax Number	:

Provider Business Practice Location Address
First Line	:	2505 CLUB PL
Second Line	:
City	:	DULUTH
State	:	GA
Zip	:	30096-8218
Country	:	US
Telephone Number	:	954-451-4116
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2021
Last Update Date	:	09/28/2021

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Directions to “ TRACEY CIVIL ” Practice Location

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