=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194491308
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEARLS OF GRACE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2021
-----------------------------------------------------
Last Update Date | 06/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 414 BAXTER AVE STE 205
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40204-1198
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-917-2028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 424 E CENTRAL BLVD # 545
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32801-1923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | NIGISTI HISMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-917-2028
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------