MEDICARE: LAKAYES GRACIOUS HOME HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	347C00000X	Private Vehicle
2	343800000X	Secured Medical Transport (VAN)
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1629808274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKAYES GRACIOUS HOME HEALTH

Provider Business Mailing Address
First Line	:	PO BOX 1722
Second Line	:
City	:	TEXAS CITY
State	:	TX
Zip	:	77592-1722
Country	:	US
Telephone Number	:	832-986-2826
Fax Number	:

Provider Business Practice Location Address
First Line	:	1807 TANGLEBERRY CT
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-7520
Country	:	US
Telephone Number	:	832-986-2826
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TIMEKA KOTUN
Credential	:
Telephone Number	:	832-986-2826

Provider Enumeration Date	:	08/07/2024
Last Update Date	:	08/14/2024

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