Healthcare Provider Details

I. General information

NPI: 1023353588
Provider Name (Legal Business Name): AMAZING GRACE HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E GRANT ST APT. 311
MINNEAPOLIS MN
55404-1400
US

IV. Provider business mailing address

515 E GRANT ST APT. 311
MINNEAPOLIS MN
55404-1400
US

V. Phone/Fax

Practice location:
  • Phone: 651-329-1853
  • Fax: 612-343-8618
Mailing address:
  • Phone: 651-329-1853
  • Fax: 612-343-8618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number374448
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code3140N1450X
TaxonomyPediatric Skilled Nursing Facility
License Number374448
License Number StateMN

VIII. Authorized Official

Name: NNEKA ADAEZE OGBU
Title or Position: CEO/PRESIDENT
Credential: BSC/MPH
Phone: 651-329-1853