=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417412453
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACIOUS HOME HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2019
-----------------------------------------------------
Last Update Date | 02/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2165 MORRIS AVE STE 19
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-5913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-810-1044
-----------------------------------------------------
Fax | 908-810-1077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1514 ROSE TER
-----------------------------------------------------
City | UNION
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07083-4726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-810-1044
-----------------------------------------------------
Fax | 908-810-1077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF NURSING
-----------------------------------------------------
Name | MRS. ESTHER AGBONMA EWEH
-----------------------------------------------------
Credential | RN BSN
-----------------------------------------------------
Telephone | 908-810-1044
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------