MEDICARE: GRACE MEDICAL TRANSPORT LLC

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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1285576066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE MEDICAL TRANSPORT LLC

Provider Business Mailing Address
First Line	:	803 S CENTER ST
Second Line	:
City	:	BLOOMINGTON
State	:	IL
Zip	:	61701-6452
Country	:	US
Telephone Number	:	309-207-6768
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 1/2 W NORTH ST STE C
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-2587
Country	:	US
Telephone Number	:	773-302-9714
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	QUNSHAWN GARDNER
Credential	:
Telephone Number	:	309-207-6768

Provider Enumeration Date	:	04/08/2026
Last Update Date	:	06/08/2026

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Directions to “GRACE MEDICAL TRANSPORT LLC ” Practice Location

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