Provider Demographics
NPI:1194287425
Name:GRACERIDGE INC
Entity type:Organization
Organization Name:GRACERIDGE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GROJEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-530-9706
Mailing Address - Street 1:902 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3801
Mailing Address - Country:US
Mailing Address - Phone:870-530-9706
Mailing Address - Fax:
Practice Address - Street 1:3909 HILL DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8850
Practice Address - Country:US
Practice Address - Phone:870-935-5961
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR223545732Medicaid