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General NPI Number Information
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NPI Number | 1083876502
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Entity Type | Organization
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Legal Business Name | PATRICKGRAPEVINE
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Dates
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Enumeration Date | 06/26/2008
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Last Update Date | 06/26/2008
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Provider Practice Location Address
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Address Line | 1833 SOUTH THIRD STREET
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City | MEMPHIS
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State | TN
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Zip | 38109
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Country | US
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Telephone | 901-550-1011
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Fax |
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Provider Business Mailing Address
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Address Line | 1833 S 3RD ST
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City | MEMPHIS
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State | TN
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Zip | 38109-7717
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT CEO
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Name | MR. COLEMAN THOMPSON
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Credential |
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Telephone | 901-550-1011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 0000000475
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License Number State | TN
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