MEDICARE: RICHARD BRADLEY GRACE CRNA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	088595	TX

General Provider Information

NPI Number	:	1083984579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD BRADLEY GRACE CRNA

Provider Business Mailing Address
First Line	:	10109 HIGH BLUFF DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-4018
Country	:	US
Telephone Number	:	325-668-0563
Fax Number	:

Provider Business Practice Location Address
First Line	:	10109 HIGH BLUFF DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76108-4018
Country	:	US
Telephone Number	:	325-668-0563
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/30/2011
Last Update Date	:	12/30/2011

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Directions to “ RICHARD BRADLEY GRACE CRNA” Practice Location

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