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General NPI Number Information
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NPI Number | 1679060065
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Entity Type | Organization
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Legal Business Name | GRACECARE MOBILE RESPONSE LLC
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Dates
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Enumeration Date | 04/20/2018
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Last Update Date | 04/20/2018
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Provider Practice Location Address
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Address Line | 3475 W SLAUSON AVE
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City | LOS ANGELES
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State | CA
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Zip | 90043-2438
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Country | US
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Telephone | 310-617-2620
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Fax |
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Provider Business Mailing Address
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Address Line | 1048 MARINE AVE APT 10
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City | GARDENA
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State | CA
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Zip | 90247-4168
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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 | MANAGER
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Name | JESSE LUCAS
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Credential |
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Telephone | 310-617-2620
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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