=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558845339
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IVORY FRANK GRAVES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2018
-----------------------------------------------------
Last Update Date | 09/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 TRADE CENTER DR W
-----------------------------------------------------
City | SAINT PETERS
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63376-1190
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-978-4300
-----------------------------------------------------
Fax | 636-978-4343
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 FOREST PEAK COURT
-----------------------------------------------------
City | ST CHARLES
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63303-5300
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-610-6834
-----------------------------------------------------
Fax | 636-493-9792
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 343900000X
-----------------------------------------------------
Taxonomy Name | Non-emergency Medical Transport (VAN)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------