=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497097638
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMAZING GACE ASSISTED LIVING HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2013
-----------------------------------------------------
Last Update Date | 03/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2685 CARAMBOLA RD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33406-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-357-9559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2685 CARAMBOLA RD
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33406-5106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ADMINISTRATOR
-----------------------------------------------------
Name | DEBORAH LYTLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-818-5790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | AL12171
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------