MEDICARE: GRACIOUS HOME HEALTH AGENCY AND MEDICAL SUPPLY INC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1053649319
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACIOUS HOME HEALTH AGENCY AND MEDICAL SUPPLY INC

Provider Business Mailing Address
First Line	:	4731 N GALLOWAY AVE
Second Line	:	SUITE 103
City	:	MESQUITE
State	:	TX
Zip	:	75150-1512
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4731 N GALLOWAY AVE
Second Line	:	SUITE 103
City	:	MESQUITE
State	:	TX
Zip	:	75150-1512
Country	:	US
Telephone Number	:	214-982-1598
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. SAMUEL EMEKA AGHAZIEM
Credential	:
Telephone Number	:	214-982-1598

Provider Enumeration Date	:	11/25/2009
Last Update Date	:	08/19/2014

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