Healthcare Provider Details

I. General information

NPI: 1619331451
Provider Name (Legal Business Name): GRACE CARE SER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2016
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 E CENTRAL AVE
WINTER HAVEN FL
33880-3047
US

IV. Provider business mailing address

395 E CENTRAL AVE
WINTER HAVEN FL
33880-3047
US

V. Phone/Fax

Practice location:
  • Phone: 863-585-0147
  • Fax: 863-875-5348
Mailing address:
  • Phone: 863-585-0147
  • Fax: 863-875-5348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANELL S CODY
Title or Position: OWNER
Credential:
Phone: 863-585-0147