Provider Demographics
NPI:1255024113
Name:GRACE MEDICAL TRANSPORT LLC
Entity type:Organization
Organization Name:GRACE MEDICAL TRANSPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:229-396-5791
Mailing Address - Street 1:117 3RD ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-4879
Mailing Address - Country:US
Mailing Address - Phone:229-396-5791
Mailing Address - Fax:229-396-4046
Practice Address - Street 1:117 3RD ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4879
Practice Address - Country:US
Practice Address - Phone:229-396-5791
Practice Address - Fax:229-396-4046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)