MEDICARE: GRACE OUTREACH

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	3245S0500X	Children's Substance Abuse Rehabilitation Facility
2	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1275093841
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE OUTREACH

Provider Business Mailing Address
First Line	:	3225 TURTLE CREEK BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-5409
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3225 TURTLE CREEK BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-5409
Country	:	US
Telephone Number	:	225-335-2240
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TOMMY BROWN
Credential	:	TRS, RN
Telephone Number	:	225-335-2240

Provider Enumeration Date	:	03/21/2019
Last Update Date	:	10/28/2020

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Directions to “GRACE OUTREACH ” Practice Location

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