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General NPI Number Information
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NPI Number | 1316121742
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Entity Type | Organization
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Legal Business Name | AMAZING GRACE RESIDENTIAL SERVICES AGENCY
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Dates
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Enumeration Date | 12/20/2007
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Last Update Date | 12/20/2007
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Provider Practice Location Address
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Address Line | 8645 VINTAGE EARTH PATH
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City | LAUREL
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State | MD
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Zip | 20723-5880
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Country | US
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Telephone | 301-497-4117
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Fax |
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Provider Business Mailing Address
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Address Line | 8645 VINTAGE EARTH PATH
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City | LAUREL
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State | MD
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Zip | 20723-5880
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Country | US
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Telephone | 301-497-4117
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. EDWARD O LANLOKUN
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Credential |
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Telephone | 301-497-4117
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | R2546
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License Number State | MD
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