MEDICARE: GRACIOUS CARE RECOVERY

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1902158025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACIOUS CARE RECOVERY

Provider Business Mailing Address
First Line	:	635 SE 10TH ST STE B
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-5607
Country	:	US
Telephone Number	:	754-201-2265
Fax Number	:

Provider Business Practice Location Address
First Line	:	635 SE 10TH ST STE B
Second Line	:
City	:	DEERFIELD BEACH
State	:	FL
Zip	:	33441-5607
Country	:	US
Telephone Number	:	754-201-2265
Fax Number	:

Authorized Official
Title or Position	:	ACCOUNT SPECIALIST
Name	:	JOSE FLORES
Credential	:
Telephone Number	:	754-201-2265

Provider Enumeration Date	:	10/12/2012
Last Update Date	:	10/12/2012

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