MEDICARE: MS. MANETTE ELAINE GRAHAM PRESIDENT OF THE 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1588265334
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MANETTE ELAINE GRAHAM PRESIDENT OF THE LLC

Provider Business Mailing Address
First Line	:	1717 EAST CAYUGA ST.
Second Line	:	SAME
City	:	TAMPA
State	:	FL
Zip	:	33610
Country	:	US
Telephone Number	:	813-665-5536
Fax Number	:

Provider Business Practice Location Address
First Line	:	1717 E CAYUGA ST
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33610-6025
Country	:	US
Telephone Number	:	813-665-5536
Fax Number	:

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

Provider Enumeration Date	:	11/06/2020
Last Update Date	:	11/06/2020

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