=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477931764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE ADULT FAMILY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2015
-----------------------------------------------------
Last Update Date | 05/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2947 N COLORADO AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46218-3116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-427-3755
-----------------------------------------------------
Fax | 317-816-7304
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2825 E 96TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46240-1310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-427-3755
-----------------------------------------------------
Fax | 317-816-7304
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. JOY ADEWOPO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 317-427-3755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 201279870
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------