Healthcare Provider Details

I. General information

NPI: 1942158167
Provider Name (Legal Business Name): MR. GRADY EDWARDS III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2026
Last Update Date: 03/21/2026
Certification Date: 03/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 MELLON ST SE
WASHINGTON DC
20032-2537
US

IV. Provider business mailing address

617 MELLON ST SE
WASHINGTON DC
20032-2537
US

V. Phone/Fax

Practice location:
  • Phone: 202-706-1431
  • Fax: 202-562-0963
Mailing address:
  • Phone: 202-706-1431
  • Fax: 202-562-0963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number271261516045
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: