Healthcare Provider Details

I. General information

NPI: 1730456575
Provider Name (Legal Business Name): AMAZING GRACE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 W BEECHER ST
INDIANAPOLIS IN
46241-4603
US

IV. Provider business mailing address

4825 W BEECHER ST
INDIANAPOLIS IN
46241-4603
US

V. Phone/Fax

Practice location:
  • Phone: 614-260-7834
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number28198833A
License Number StateIN

VIII. Authorized Official

Name: MISS ROSY ALAGBE
Title or Position: REGISTERED NURSE
Credential:
Phone: 614-260-7834