MEDICARE: MRS. EUGENIE GRANT CNA/PERS. ASST.

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	374U00000X	Home Health Aide	1232	FL
2	376K00000X	Nurse's Aide	1289	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619278694
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. EUGENIE GRANT CNA/PERS. ASST.

Provider Business Mailing Address
First Line	:	3112 SW WATSON CT
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6302
Country	:	US
Telephone Number	:	772-344-3531
Fax Number	:

Provider Business Practice Location Address
First Line	:	3112 SW WATSON CT
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34953-6302
Country	:	US
Telephone Number	:	772-344-3531
Fax Number	:

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

Provider Enumeration Date	:	11/08/2010
Last Update Date	:	11/08/2010

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