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General NPI Number Information
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NPI Number | 1497635338
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Entity Type | Organization
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Legal Business Name | GRACE FRIENDSHIP HOME LLC
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Dates
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Enumeration Date | 09/03/2025
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Last Update Date | 09/03/2025
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Provider Practice Location Address
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Address Line | 4736 NW 5TH AVE
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City | DEERFIELD BEACH
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State | FL
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Zip | 33064-2563
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Country | US
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Telephone | 954-401-2806
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Fax | 954-401-2806
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Provider Business Mailing Address
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Address Line | 2925 SW BOXWOOD CIR
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City | PORT SAINT LUCIE
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State | FL
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Zip | 34953-6966
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Country | US
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Telephone | 954-401-2806
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Fax | 954-401-2806
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Authorized Official
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Title or Position | OWNER
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Name | HENRIETTA G JACKSON
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Credential |
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Telephone | 954-401-2806
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 373H00000X
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Taxonomy Name | Day Training/Habilitation Specialist
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License Number |
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License Number State |
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