Healthcare Provider Details

I. General information

NPI: 1164638565
Provider Name (Legal Business Name): AMAZING GRACE PERSONAL CARE SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4131 BARBARA LOOP SE # 2D
RIO RANCHO NM
87124-1362
US

IV. Provider business mailing address

4131 BARBARA LOOP SE # 2D
RIO RANCHO NM
87124-1362
US

V. Phone/Fax

Practice location:
  • Phone: 505-796-4900
  • Fax: 505-896-4513
Mailing address:
  • Phone: 505-863-5898
  • Fax: 505-896-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TOM CRIDER
Title or Position: OWNER
Credential: M. DIV
Phone: 505-796-4900