MEDICARE: A GRACEFUL WAY, LLC

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	253Z00000X	In Home Supportive Care Agency	201317810050	CA

General Provider Information

NPI Number	:	1720494578
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A GRACEFUL WAY, LLC

Provider Business Mailing Address
First Line	:	6307 5TH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-4257
Country	:	US
Telephone Number	:	310-857-9644
Fax Number	:	323-753-6645

Provider Business Practice Location Address
First Line	:	6307 5TH AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-4257
Country	:	US
Telephone Number	:	310-857-9644
Fax Number	:	323-753-6645

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MR. RYAN SULLIVAN REEDOM
Credential	:
Telephone Number	:	310-857-9644

Provider Enumeration Date	:	07/01/2014
Last Update Date	:	07/01/2014

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