MEDICARE: MARYS HOUSE OF RESTORATION, INC.

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	405300000X	Prevention Professional
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1114644598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARYS HOUSE OF RESTORATION, INC.

Provider Business Mailing Address
First Line	:	9320 CLOVERHILL RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4617
Country	:	US
Telephone Number	:	501-744-8799
Fax Number	:	501-747-1149

Provider Business Practice Location Address
First Line	:	9320 CLOVERHILL RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72205-4617
Country	:	US
Telephone Number	:	501-744-8799
Fax Number	:	501-747-1149

Authorized Official
Title or Position	:	CHEIF EXECUTIVE OFFICER
Name	:	MISS CARLA M GRANTT
Credential	:
Telephone Number	:	501-744-8799

Provider Enumeration Date	:	10/26/2022
Last Update Date	:	10/26/2022

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