MEDICARE: GRACE LAND RECOVERY LLC

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	261Q00000X	Clinic/Center
2	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1245821966
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE LAND RECOVERY LLC

Provider Business Mailing Address
First Line	:	134 TIMBER CREEK DR
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-4291
Country	:	US
Telephone Number	:	901-519-2655
Fax Number	:	404-698-1497

Provider Business Practice Location Address
First Line	:	134 TIMBER CREEK DR
Second Line	:
City	:	CORDOVA
State	:	TN
Zip	:	38018-4291
Country	:	US
Telephone Number	:	901-519-2655
Fax Number	:	404-698-1497

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. BRETT ARIC NELSON
Credential	:	MD
Telephone Number	:	404-620-9745

Provider Enumeration Date	:	01/27/2021
Last Update Date	:	12/22/2021

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Directions to “GRACE LAND RECOVERY LLC ” Practice Location

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