Provider Demographics
NPI:1003321662
Name:GRACE CARE AMBULANCE TRANSPORT, LLC
Entity Type:Organization
Organization Name:GRACE CARE AMBULANCE TRANSPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLTON
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:ANTHONY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-585-4857
Mailing Address - Street 1:2372 S STONE MOUNTAIN RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058
Mailing Address - Country:US
Mailing Address - Phone:404-585-4857
Mailing Address - Fax:404-393-4041
Practice Address - Street 1:516 SOSEBEE FARM RD UNIT 531
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-0118
Practice Address - Country:US
Practice Address - Phone:404-585-4857
Practice Address - Fax:404-393-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-05
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport