Healthcare Provider Details

I. General information

NPI: 1619647179
Provider Name (Legal Business Name): GRACEFUL HOME SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 BLACKWOOD DR
MULBERRY FL
33860-5500
US

IV. Provider business mailing address

2236 BLACKWOOD DR
MULBERRY FL
33860-5500
US

V. Phone/Fax

Practice location:
  • Phone: 863-258-4147
  • Fax:
Mailing address:
  • Phone: 863-258-4147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE ROBERTSON
Title or Position: OWNER
Credential:
Phone: 863-258-4147