Healthcare Provider Details

I. General information

NPI: 1073257101
Provider Name (Legal Business Name): GRACE MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2022
Last Update Date: 04/25/2022
Certification Date: 04/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 2ND AVE S SUITE 112
OKANOGAN WA
98840
US

IV. Provider business mailing address

202 E BARTLETT AVE
OMAK WA
98841-9332
US

V. Phone/Fax

Practice location:
  • Phone: 509-557-6300
  • Fax: 509-557-6380
Mailing address:
  • Phone: 509-557-6300
  • Fax: 509-557-6380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: JILL SCOTT
Title or Position: OWNER
Credential:
Phone: 509-557-6300