Healthcare Provider Details

I. General information

NPI: 1902716343
Provider Name (Legal Business Name): GREAT GRACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5251 GALITZ ST
SKOKIE IL
60077-3669
US

IV. Provider business mailing address

5251 GALITZ ST
SKOKIE IL
60077-3669
US

V. Phone/Fax

Practice location:
  • Phone: 872-235-5646
  • Fax:
Mailing address:
  • Phone: 872-235-5646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: SYNTHIA FOMUM
Title or Position: PRESIDENT
Credential: CEO
Phone: 872-235-5646