MEDICARE: GREATER GRACE FAMILY SERVICES 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	103K00000X	Behavior Analyst		NV

General Provider Information

NPI Number	:	1821506049
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREATER GRACE FAMILY SERVICES LLC

Provider Business Mailing Address
First Line	:	3517 AMISH AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-3591
Country	:	US
Telephone Number	:	702-981-1044
Fax Number	:

Provider Business Practice Location Address
First Line	:	3517 AMISH AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-3591
Country	:	US
Telephone Number	:	702-981-1044
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAREAL S THOMAS
Credential	:
Telephone Number	:	702-981-1044

Provider Enumeration Date	:	01/22/2018
Last Update Date	:	01/22/2018

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