Healthcare Provider Details

I. General information

NPI: 1760199806
Provider Name (Legal Business Name): GRACE & MERCY PERSONAL CARE PROVIDER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2022
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 GWENN RAY DR
EUPORA MS
39744-3403
US

IV. Provider business mailing address

24224 MS HIGHWAY 15
MATHISTON MS
39752-6876
US

V. Phone/Fax

Practice location:
  • Phone: 662-258-1018
  • Fax:
Mailing address:
  • Phone: 662-263-3194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: MRS. OLEAN DENISE PITTMAN
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 662-262-3194