Provider Demographics
NPI:1053649319
Name:GRACIOUS HOME HEALTH AGENCY AND MEDICAL SUPPLY INC
Entity Type:Organization
Organization Name:GRACIOUS HOME HEALTH AGENCY AND MEDICAL SUPPLY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:EMEKA
Authorized Official - Last Name:AGHAZIEM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-982-1598
Mailing Address - Street 1:4731 N GALLOWAY AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-1512
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4731 N GALLOWAY AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-1512
Practice Address - Country:US
Practice Address - Phone:214-982-1598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-25
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health