MEDICARE: HIS GRACE MEDICAL SUPPLY AND MORE

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	332B00000X	Durable Medical Equipment & Medical Supplies	0100320	TX

General Provider Information

NPI Number	:	1871763185
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIS GRACE MEDICAL SUPPLY AND MORE

Provider Business Mailing Address
First Line	:	PO BOX 153202
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76015-9202
Country	:	US
Telephone Number	:	817-557-1668
Fax Number	:	888-441-6930

Provider Business Practice Location Address
First Line	:	1901 SOUTHEAST PKWY
Second Line	:	SUITE 106
City	:	ARLINGTON
State	:	TX
Zip	:	76018-3605
Country	:	US
Telephone Number	:	817-557-1668
Fax Number	:

Authorized Official
Title or Position	:	MANAGING EMPLOYEE
Name	:	PAMELA O. ADENUGA
Credential	:
Telephone Number	:	817-557-1668

Provider Enumeration Date	:	03/04/2008
Last Update Date	:	07/16/2009

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