Provider Demographics
NPI:1558845339
Name:GRAVES, IVORY FRANK
Entity Type:Individual
Prefix:
First Name:IVORY
Middle Name:FRANK
Last Name:GRAVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 FOREST PEAK COURT
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5300
Mailing Address - Country:US
Mailing Address - Phone:314-610-6834
Mailing Address - Fax:636-493-9792
Practice Address - Street 1:200 TRADE CENTER DR W
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1190
Practice Address - Country:US
Practice Address - Phone:636-978-4300
Practice Address - Fax:636-978-4343
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)