Provider Demographics
NPI:1699057539
Name:GRAHAMPROFESSIONALSERVICES
Entity type:Organization
Organization Name:GRAHAMPROFESSIONALSERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ C.E.O
Authorized Official - Prefix:
Authorized Official - First Name:DAVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-801-6336
Mailing Address - Street 1:181 MARTENSE ST
Mailing Address - Street 2:SUITE 3W
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-3336
Mailing Address - Country:US
Mailing Address - Phone:718-801-6336
Mailing Address - Fax:347-295-1211
Practice Address - Street 1:181 MARTENSE ST
Practice Address - Street 2:SUITE 3W
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-3336
Practice Address - Country:US
Practice Address - Phone:718-801-6336
Practice Address - Fax:347-295-1211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274597557305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service