Healthcare Provider Details

I. General information

NPI: 1639543655
Provider Name (Legal Business Name): RESIDENT OF THE GRAYSTONE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2015
Last Update Date: 11/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 OAK VILLAGE BLVD
ARLINGTON TX
76017
US

IV. Provider business mailing address

PO BOX 171747 346
ARLINGTON TX
76003
US

V. Phone/Fax

Practice location:
  • Phone: 682-305-2290
  • Fax: 682-305-2284
Mailing address:
  • Phone: 682-305-2290
  • Fax: 682-305-2284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. TAHYAHNEETAH WALKER
Title or Position: CEO/OWNER
Credential:
Phone: 682-305-2290