Basic Information
| Provider Information | |||||||||
| NPI: | 1972814127 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACE HEALTHCARE DME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 BROAD AVENUE | ||||||||
| Address2: | |||||||||
| City: | GULFPORT | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288633331 | ||||||||
| FaxNumber: | 2288633392 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 HIGHWAY 11 | ||||||||
| Address2: | SUITE D | ||||||||
| City: | POPLARVILLE | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39470 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012400001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2010 | ||||||||
| LastUpdateDate: | 06/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | WOLF | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2288633331 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.