MEDICARE: GRACIOUS HAVEN HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251J00000X	Nursing Care Agency
2	253Z00000X	In Home Supportive Care Agency
3	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1790141281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACIOUS HAVEN HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 64636
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85728-4636
Country	:	US
Telephone Number	:	520-975-3119
Fax Number	:	520-844-1522

Provider Business Practice Location Address
First Line	:	3843 E PRESIDIO RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85716-1736
Country	:	US
Telephone Number	:	520-975-3119
Fax Number	:	520-844-1522

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. CHRISTIE GAGNON
Credential	:
Telephone Number	:	520-975-3119

Provider Enumeration Date	:	01/13/2016
Last Update Date	:	01/13/2016

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