Healthcare Provider Details

I. General information

NPI: 1215395900
Provider Name (Legal Business Name): GRACE SUPPORTIVE LIVING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 RIVERWOOD PKWY SE 1900
ATLANTA GA
30339-6401
US

IV. Provider business mailing address

3350 RIVERWOOD PKWY SE 1900
ATLANTA GA
30339-6401
US

V. Phone/Fax

Practice location:
  • Phone: 770-984-5388
  • Fax:
Mailing address:
  • Phone: 770-984-5388
  • Fax:

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 NumberLPN0089404
License Number StateGA

VIII. Authorized Official

Name: MS. SAMARA L ROBERTSON
Title or Position: OWNER/LICENSE NURSE
Credential: LPN
Phone: 770-984-5388