MEDICARE: GRACE WELLNESS & REHABILITATION, 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	261QR0400X	Rehabilitation Clinic/Center	554930000	TX

General Provider Information

NPI Number	:	1326290321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE WELLNESS & REHABILITATION, LLC

Provider Business Mailing Address
First Line	:	PO BOX 1804
Second Line	:
City	:	LAKE DALLAS
State	:	TX
Zip	:	75065-1804
Country	:	US
Telephone Number	:	214-629-6635
Fax Number	:

Provider Business Practice Location Address
First Line	:	3119 BERKSHIRE LN
Second Line	:
City	:	CORINTH
State	:	TX
Zip	:	76210-1726
Country	:	US
Telephone Number	:	214-629-6635
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	GRACE EUBANKS
Credential	:	OT
Telephone Number	:	214-629-6635

Provider Enumeration Date	:	10/21/2008
Last Update Date	:	10/21/2008

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