Healthcare Provider Details

I. General information

NPI: 1952172728
Provider Name (Legal Business Name): GRACIOUS SOUL HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2024
Last Update Date: 01/11/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4719 NORTHBAY DR SE
MANDAN ND
58554-4787
US

IV. Provider business mailing address

4719 NORTHBAY DR SE
MANDAN ND
58554-4787
US

V. Phone/Fax

Practice location:
  • Phone: 701-527-5178
  • Fax:
Mailing address:
  • Phone: 701-527-5178
  • 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 Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name: MISS NYAMAH KEYMAH II
Title or Position: CNA
Credential: CNA
Phone: 701-989-8872