Healthcare Provider Details

I. General information

NPI: 1508950197
Provider Name (Legal Business Name): GRACE MEDICAL EQUIPMENT, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 N. GRAND AVE
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

1516 N GRAND AVE
TAHLEQUAH OK
74464-6318
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-9600
  • Fax: 918-453-9601
Mailing address:
  • Phone: 918-453-9600
  • Fax: 918-453-9601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number36-S-1169
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200081550A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name: MR. NATHAN PAUL PENNINGTON
Title or Position: MANAGING MEMBER
Credential:
Phone: 918-453-9600