Healthcare Provider Details

I. General information

NPI: 1174062525
Provider Name (Legal Business Name): GRACE HAVEN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 02/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 W VOLUSIA AVE
DELAND FL
32720-6831
US

IV. Provider business mailing address

216 W VOLUSIA AVE
DELAND FL
32720-6831
US

V. Phone/Fax

Practice location:
  • Phone: 386-847-5414
  • Fax:
Mailing address:
  • Phone: 386-847-5414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number39969574
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SHANEKA DALON MORRIS
Title or Position: OWNER
Credential:
Phone: 386-847-5414