MEDICARE: MS. ELIZABETH GRACE GLACE-HALL

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	171W00000X	Contractor	007535-1	NY

General Provider Information

NPI Number	:	1902172471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELIZABETH GRACE GLACE-HALL

Provider Business Mailing Address
First Line	:	10579 SEAVIEW AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-4625
Country	:	US
Telephone Number	:	718-629-2737
Fax Number	:

Provider Business Practice Location Address
First Line	:	1070 E 83RD ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11236-4226
Country	:	US
Telephone Number	:	718-241-5757
Fax Number	:

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

Provider Enumeration Date	:	03/28/2012
Last Update Date	:	03/28/2012

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