Healthcare Provider Details

I. General information

NPI: 1639368129
Provider Name (Legal Business Name): HOUSE OF GRACE PERSONAL CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 10/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 JENNA LN
COVINGTON GA
30016-6645
US

IV. Provider business mailing address

80 JENNA LN
COVINGTON GA
30016-6645
US

V. Phone/Fax

Practice location:
  • Phone: 404-549-0877
  • Fax:
Mailing address:
  • Phone: 404-549-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateGA

VIII. Authorized Official

Name: MR. JEAN P STFLEUR
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-549-0877