Basic Information
| Provider Information | |||||||||
| NPI: | 1811229644 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACE HEALTHCARE MEDICAL INC. | ||||||||
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| OtherOrganizationName: | GRACE HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 W GERMANTOWN PIKE STE 250 | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH MEETING | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194621437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106306357 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2609 CATALPA AVE | ||||||||
| Address2: | |||||||||
| City: | PASCAGOULA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395671806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288633331 | ||||||||
| FaxNumber: | 2288633392 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2010 | ||||||||
| LastUpdateDate: | 06/09/2021 | ||||||||
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| AuthorizedOfficialLastName: | GRIGGS | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO, PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4072060040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AEROCARE HOLDINGS LLC | ||||||||
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| NPICertificationDate: | 06/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 332BX2000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
ID Information
| ID | Type | State | Issuer | Description | 03752061 | 05 | MS | MEDICAID |