Healthcare Provider Details

I. General information

NPI: 1629982855
Provider Name (Legal Business Name): GRACE BRIDGE HOMECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

533 NEWTOWN RD STE 117
VIRGINIA BEACH VA
23462-5758
US

IV. Provider business mailing address

533 NEWTOWN RD STE 117
VIRGINIA BEACH VA
23462-5758
US

V. Phone/Fax

Practice location:
  • Phone: 757-581-4062
  • Fax:
Mailing address:
  • Phone: 757-581-4062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. JOHN LATSE WALLACE
Title or Position: DIRECTOR
Credential:
Phone: 757-581-4062