MEDICARE: EZEKIEL GRANT INDEPENDENT LIVING

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	311Z00000X	Custodial Care Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	804467126	OTHER	TX	BUSINESS CODED
2	804467126	OTHER	TX	BUSINESS FILE NUMBER

General Provider Information

NPI Number	:	1649912676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EZEKIEL GRANT INDEPENDENT LIVING

Provider Business Mailing Address
First Line	:	440 BENMAR DR STE 1395
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77060-3172
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	440 BENMAR DR STE 1395
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77060-3172
Country	:	US
Telephone Number	:	832-863-1556
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FRANCES GRANT
Credential	:
Telephone Number	:	832-863-1556

Provider Enumeration Date	:	04/11/2022
Last Update Date	:	04/11/2022

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