Provider Demographics
NPI:1548249899
Name:GRACE HOME RESPIRATORY INC
Entity type:Organization
Organization Name:GRACE HOME RESPIRATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:WILLIS
Authorized Official - Last Name:RACLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:715-832-7377
Mailing Address - Street 1:2204 N HILLCREST PKWY
Mailing Address - Street 2:SUITE #2
Mailing Address - City:ALTOONA
Mailing Address - State:WI
Mailing Address - Zip Code:54720-2626
Mailing Address - Country:US
Mailing Address - Phone:715-832-7377
Mailing Address - Fax:715-832-7031
Practice Address - Street 1:2204 N HILLCREST PKWY
Practice Address - Street 2:SUITE #2
Practice Address - City:ALTOONA
Practice Address - State:WI
Practice Address - Zip Code:54720-2626
Practice Address - Country:US
Practice Address - Phone:715-832-7377
Practice Address - Fax:715-832-7031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-14
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI004-00002711120-01332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41704400Medicaid
WI4462120001Medicare NSC