MEDICARE: JIMMY LEE GRAHAM

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	374U00000X	Home Health Aide

General Provider Information

NPI Number	:	1790867380
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JIMMY LEE GRAHAM

Provider Business Mailing Address
First Line	:	13901 SE 71ST PLACE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73115
Country	:	US
Telephone Number	:	405-386-4623
Fax Number	:

Provider Business Practice Location Address
First Line	:	13901 SE 71ST PLACE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73115
Country	:	US
Telephone Number	:	405-386-4623
Fax Number	:

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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