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General NPI Number Information
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NPI Number | 1417450891
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Entity Type | Organization
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Legal Business Name | GRACE INDEPENDENT LIVING STORE, LLC
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Dates
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Enumeration Date | 03/13/2018
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Last Update Date | 03/13/2018
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Provider Practice Location Address
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Address Line | 655 LAKE HARBOUR DR STE 1100
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City | RIDGELAND
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State | MS
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Zip | 39157-4360
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Country | US
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Telephone | 601-499-5350
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1140
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City | RIDGELAND
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State | MS
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Zip | 39158-1140
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Country | US
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Telephone | 601-499-5350
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Fax |
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Authorized Official
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Title or Position | C.E.O./OWNER
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Name | MS. JUNE M ALFORD
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Credential |
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Telephone | 601-260-6674
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number |
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 332B00000X
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Taxonomy Name | Durable Medical Equipment & Medical Supplies
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License Number | 16852.11.1
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License Number State | MS
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