Healthcare Provider Details

I. General information

NPI: 1720662687
Provider Name (Legal Business Name): GRACIOUS CARING HOME HEALTH AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2021
Last Update Date: 05/07/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PALM COAST PLAZA 3044 S MILITARY TR. SUITE G OFFICE#105
LAKE WORTH FL
33463
US

IV. Provider business mailing address

PALM COAST PLAZA 3044 S MILITARY TR. SUITE G OFFICE#105
LAKE WORTH FL
33463
US

V. Phone/Fax

Practice location:
  • Phone: 561-503-1406
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name: ISLANDE JOSEPH
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 561-503-1406