MEDICARE: BRAXTON GRIMES

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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1184293292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRAXTON GRIMES

Provider Business Mailing Address
First Line	:	6501 W CHARLESTON BLVD APT 10
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1044
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6501 W CHARLESTON BLVD APT 10
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1044
Country	:	US
Telephone Number	:	725-206-5714
Fax Number	:	725-214-5555

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

Provider Enumeration Date	:	06/22/2021
Last Update Date	:	06/22/2021

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Directions to “ BRAXTON GRIMES ” Practice Location

Language	Start Address	Practice Location

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