Healthcare Provider Details

I. General information

NPI: 1265316327
Provider Name (Legal Business Name): SOUTHERN GRACE HOME HEALTH CARE AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2025
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9709 NC HIGHWAY 72
PEMBROKE NC
28372-8055
US

IV. Provider business mailing address

9709 NC HIGHWAY 72
PEMBROKE NC
28372-8055
US

V. Phone/Fax

Practice location:
  • Phone: 910-668-0597
  • Fax: 910-302-7899
Mailing address:
  • Phone: 910-668-0597
  • Fax: 910-302-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: GABRIELLE M JONES
Title or Position: OWNER/DIRECTOR
Credential: BSN, RN
Phone: 910-301-2080