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General NPI Number Information
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NPI Number | 1033738554
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Entity Type | Organization
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Legal Business Name | AGEGRACE, INC.
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Dates
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Enumeration Date | 04/14/2020
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Last Update Date | 11/05/2020
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Provider Practice Location Address
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Address Line | 635 PHALEN BLVD APT 401
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City | SAINT PAUL
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State | MN
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Zip | 55130-5308
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Country | US
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Telephone | 612-707-8121
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 28041
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City | OAKDALE
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State | MN
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Zip | 55128-0041
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Country | US
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Telephone | 612-707-8121
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Fax |
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Authorized Official
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Title or Position | CEO/ADMINISTRATOR
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Name | JENNIFER OWENS
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Credential | QDDS
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Telephone | 612-707-8121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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