Healthcare Provider Details

I. General information

NPI: 1679313225
Provider Name (Legal Business Name): GRACE PATH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12195 ELK RDG
WESLEY AR
72773-9109
US

IV. Provider business mailing address

12195 ELK RDG
WESLEY AR
72773-9109
US

V. Phone/Fax

Practice location:
  • Phone: 479-225-3505
  • Fax:
Mailing address:
  • Phone: 479-225-3505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER BOWEN
Title or Position: OWNER
Credential: RN
Phone: 918-575-4849