Healthcare Provider Details

I. General information

NPI: 1780107284
Provider Name (Legal Business Name): HIS GRACE HOME HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 LAKE CAROLINA DR
COLUMBIA SC
29229-7048
US

IV. Provider business mailing address

2112 LAKE CAROLINA DR
COLUMBIA SC
29229-7048
US

V. Phone/Fax

Practice location:
  • Phone: 301-768-7878
  • Fax:
Mailing address:
  • Phone: 301-768-7878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: OLUWASEUN BANKOLE
Title or Position: OWNER
Credential:
Phone: 301-768-7878