Healthcare Provider Details

I. General information

NPI: 1477405439
Provider Name (Legal Business Name): GRACEFUL HOME CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2026
Last Update Date: 02/12/2026
Certification Date: 02/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2363 SHIMMERY LN
LAKE WORTH FL
33462-6001
US

IV. Provider business mailing address

2363 SHIMMERY LN
LAKE WORTH FL
33462-6001
US

V. Phone/Fax

Practice location:
  • Phone: 516-738-1511
  • Fax:
Mailing address:
  • Phone: 516-738-1511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RUSSHELL GORDON
Title or Position: DIRECTOR
Credential: CNA
Phone: 516-738-1511