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General NPI Number Information
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NPI Number | 1194287425
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Entity Type | Organization
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Legal Business Name | GRACERIDGE INC
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Dates
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Enumeration Date | 04/04/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 3909 HILL DR
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City | JONESBORO
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State | AR
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Zip | 72401-8850
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Country | US
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Telephone | 870-935-5961
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Fax |
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Provider Business Mailing Address
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Address Line | 902 CHESTNUT ST
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City | JONESBORO
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State | AR
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Zip | 72401-3801
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Country | US
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Telephone | 870-530-9706
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. KELLY GROJEAN
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Credential |
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Telephone | 870-530-9706
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3747A0650X
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Taxonomy Name | Attendant Care Provider
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License Number |
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License Number State |
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