MEDICARE: HIS GRACE HEALTHCARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1194243816
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HIS GRACE HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	2525 TILLER LN STE 109
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-2267
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 TILLER LN STE 109
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43231-2267
Country	:	US
Telephone Number	:	614-556-1079
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	OLAIMATU ROSE THOMAS
Credential	:
Telephone Number	:	614-556-1079

Provider Enumeration Date	:	09/01/2017
Last Update Date	:	09/01/2017

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Directions to “HIS GRACE HEALTHCARE LLC ” Practice Location

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