Provider Demographics
NPI:1164795449
Name:GRADEN PROVISION OF PROMISE OUTREACH ORG
Entity Type:Organization
Organization Name:GRADEN PROVISION OF PROMISE OUTREACH ORG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:WALTER
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:989-753-5477
Mailing Address - Street 1:2421 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601-3613
Mailing Address - Country:US
Mailing Address - Phone:989-753-5477
Mailing Address - Fax:989-753-7461
Practice Address - Street 1:2421 SHERIDAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-3613
Practice Address - Country:US
Practice Address - Phone:989-753-5477
Practice Address - Fax:989-753-7461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty