Healthcare Provider Details

I. General information

NPI: 1417005141
Provider Name (Legal Business Name): GRAHAM CC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 1ST ST
GRAHAM TX
76450-3603
US

IV. Provider business mailing address

1325 1ST ST
GRAHAM TX
76450-3603
US

V. Phone/Fax

Practice location:
  • Phone: 940-549-8787
  • Fax: 940-521-0355
Mailing address:
  • Phone: 940-549-8787
  • Fax: 940-521-0355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number114203
License Number StateTX

VIII. Authorized Official

Name: MR. RICHARD MARTIN
Title or Position: PRESIDENT
Credential:
Phone: 940-549-8787