Healthcare Provider Details

I. General information

NPI: 1265550875
Provider Name (Legal Business Name): TRACIE RENEE GRAHAM O.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 W. TYLER COVE
WEST MEMPHIS AR
72301
US

IV. Provider business mailing address

4734 BETHAY DR
MEMPHIS TN
38125-5700
US

V. Phone/Fax

Practice location:
  • Phone: 870-733-1200
  • Fax: 870-732-3269
Mailing address:
  • Phone: 901-494-3710
  • Fax: 870-733-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOTR1280
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: