MEDICARE: GRACE BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	146N00000X	Basic Emergency Medical Technician
2	343900000X	Non-emergency Medical Transport (VAN)
3	347E00000X	Transportation Broker
4	341600000X	Ambulance

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063683100
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	2336 E MAGNOLIA ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85034-6819
Country	:	US
Telephone Number	:	602-231-0102
Fax Number	:	602-231-0015

Provider Business Practice Location Address
First Line	:	2336 E MAGNOLIA ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85034-6819
Country	:	US
Telephone Number	:	602-231-0102
Fax Number	:	602-231-0015

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	CYNTHIA CROSS
Credential	:
Telephone Number	:	602-231-0102

Provider Enumeration Date	:	03/17/2008
Last Update Date	:	03/17/2008

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