MEDICARE: WILLARD TYRON GRAVES

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	225100000X	Physical Therapist	3451	GA

General Provider Information

NPI Number	:	1558894915
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILLARD TYRON GRAVES

Provider Business Mailing Address
First Line	:	275 13TH ST NE
Second Line	:	1102
City	:	ATLANTA
State	:	GA
Zip	:	30309-3694
Country	:	US
Telephone Number	:	404-483-2191
Fax Number	:

Provider Business Practice Location Address
First Line	:	275 13TH ST NE
Second Line	:	1102
City	:	ATLANTA
State	:	GA
Zip	:	30309-3694
Country	:	US
Telephone Number	:	404-483-2191
Fax Number	:

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

Provider Enumeration Date	:	04/04/2017
Last Update Date	:	04/04/2017

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