MEDICARE: MS. MARLENE GRAHAM

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	251E00000X	Home Health Agency
2	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1477170397
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARLENE GRAHAM

Provider Business Mailing Address
First Line	:	1371 PIEDMONT RD NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-4037
Country	:	US
Telephone Number	:	678-687-7561
Fax Number	:

Provider Business Practice Location Address
First Line	:	1371 PIEDMONT RD NE
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30066-4037
Country	:	US
Telephone Number	:	678-687-7561
Fax Number	:

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

Provider Enumeration Date	:	06/26/2020
Last Update Date	:	06/26/2020

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