Healthcare Provider Details

I. General information

NPI: 1598256521
Provider Name (Legal Business Name): AMAZING GRACE CAREGIVERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2018
Last Update Date: 05/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 HIGH ST
HALLOWELL ME
04347-1222
US

IV. Provider business mailing address

17 HIGH ST
HALLOWELL ME
04347-1222
US

V. Phone/Fax

Practice location:
  • Phone: 708-774-3887
  • Fax:
Mailing address:
  • Phone: 708-774-3887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: BOB C IBENEME
Title or Position: MANAGING DIRECTOR
Credential:
Phone: 708-774-3887