Healthcare Provider Details

I. General information

NPI: 1336898576
Provider Name (Legal Business Name): GRACE AND PROSPERITY ADULT DAY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 03/23/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 N THOMPSON ST
ELLAVILLE GA
31806
US

IV. Provider business mailing address

220 N THOMPSON ST
ELLAVILLE GA
31806
US

V. Phone/Fax

Practice location:
  • Phone: 229-938-3872
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SANDRA REYNOLDS
Title or Position: OWNER
Credential:
Phone: 229-938-3872