MEDICARE: GRACE ADULT FAMILY CARE 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	311ZA0620X	Adult Care Home Facility	201279870	IN

General Provider Information

NPI Number	:	1477931764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE ADULT FAMILY CARE LLC

Provider Business Mailing Address
First Line	:	2825 E 96TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1310
Country	:	US
Telephone Number	:	317-427-3755
Fax Number	:	317-816-7304

Provider Business Practice Location Address
First Line	:	2947 N COLORADO AVE
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46218-3116
Country	:	US
Telephone Number	:	317-427-3755
Fax Number	:	317-816-7304

Authorized Official
Title or Position	:	OWNER
Name	:	MS. JOY ADEWOPO
Credential	:
Telephone Number	:	317-427-3755

Provider Enumeration Date	:	05/07/2015
Last Update Date	:	05/07/2015

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