Basic Information
| Provider Information | |||||||||
| NPI: | 1326555483 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACEFUL TOUCH, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRACEFUL TOUCH, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 800 N RAINBOW BLVD | ||||||||
| Address2: | 212 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891071189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022933888 | ||||||||
| FaxNumber: | 7022933664 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 N RAINBOW BLVD | ||||||||
| Address2: | 212 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891071189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022933888 | ||||||||
| FaxNumber: | 7022933664 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2018 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7022933888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 302F00000X | 6048PCS-6 | NV | N | Managed Care Organizations | Exclusive Provider Organization | 251E00000X | 6048PCS-6 | NV | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 1538546635 | 05 | NV | MEDICAID | 1891093621 | 05 | NV | MEDICAID |