MEDICARE: GRACE HEALTHCARE STAFFING AGENCY

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1477209054
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE HEALTHCARE STAFFING AGENCY

Provider Business Mailing Address
First Line	:	4670 CORLEY ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77707-4221
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4670 CORLEY ST
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77707-4221
Country	:	US
Telephone Number	:	409-455-2762
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ANTRAMESE CARRY
Credential	:
Telephone Number	:	409-455-2762

Provider Enumeration Date	:	02/23/2022
Last Update Date	:	03/08/2022

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