=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194012799
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DYNAMIC GRACE HOME HEALTH CARE SERVICES,INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2011
-----------------------------------------------------
Last Update Date | 12/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6510 TAMRA DR
-----------------------------------------------------
City | TAYLORSVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84084-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-703-0658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6510 TAMRA DR
-----------------------------------------------------
City | TAYLORSVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84084-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-703-0658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. PATRICIA O OTIEDE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 801-703-0658
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 2011-HHA-102739
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------