MEDICARE: REJUVENATE WITH GRACE, INC.

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	1041C0700X	Clinical Social Worker	6089	FL

General Provider Information

NPI Number	:	1528325610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	REJUVENATE WITH GRACE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 561248
Second Line	:
City	:	ROCKLEDGE
State	:	FL
Zip	:	32956-1248
Country	:	US
Telephone Number	:	321-759-4325
Fax Number	:	321-632-1753

Provider Business Practice Location Address
First Line	:	130 N TROPICAL TRL
Second Line	:
City	:	MERRITT ISLAND
State	:	FL
Zip	:	32953-4737
Country	:	US
Telephone Number	:	321-759-4325
Fax Number	:	321-632-1753

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. RUTH LYNNE GRACE
Credential	:	L.C.S.W.
Telephone Number	:	321-759-4325

Provider Enumeration Date	:	04/13/2012
Last Update Date	:	06/03/2014

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