MEDICARE: GRACEY DE GREAT 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	343900000X	Non-emergency Medical Transport (VAN)

General Provider Information

NPI Number	:	1861094708
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEY DE GREAT LLC

Provider Business Mailing Address
First Line	:	PO BOX 820196
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77282-0196
Country	:	US
Telephone Number	:	832-916-9215
Fax Number	:

Provider Business Practice Location Address
First Line	:	3443 ADDICKS CLODINE RD APT 7108
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77082-3089
Country	:	US
Telephone Number	:	832-916-9215
Fax Number	:	346-229-5954

Authorized Official
Title or Position	:	MANAGER
Name	:	GRACE IBRAHIM
Credential	:
Telephone Number	:	832-916-9215

Provider Enumeration Date	:	11/16/2020
Last Update Date	:	12/21/2020

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Directions to “GRACEY DE GREAT LLC ” Practice Location

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