MEDICARE: BARBARA GRAVES INTIMATE FASHIONS

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	335E00000X	Prosthetic/Orthotic Supplier	02063560001	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	47917	OTHER	AR	PROVIDER NUMBER

General Provider Information

NPI Number	:	1154322261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BARBARA GRAVES INTIMATE FASHIONS

Provider Business Mailing Address
First Line	:	10301 N RODNEY PARHAM RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72227-4832
Country	:	US
Telephone Number	:	501-227-5537
Fax Number	:	501-227-0655

Provider Business Practice Location Address
First Line	:	10301 N RODNEY PARHAM RD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72227-4832
Country	:	US
Telephone Number	:	501-227-5537
Fax Number	:	501-227-0655

Authorized Official
Title or Position	:	STORE MANAGER
Name	:	TRINA BRICKEY
Credential	:
Telephone Number	:	501-227-5537

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	08/22/2020

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