=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649784000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOPE, LOVE AND GRACE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/21/2017
-----------------------------------------------------
Last Update Date | 11/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 PIPESTONE ST
-----------------------------------------------------
City | BENTON HARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49022-4815
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-921-3928
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 395 E DELAWARE AVE
-----------------------------------------------------
City | BENTON HARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49022-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MS. CONSTANCE DOMINIQUE ADAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-921-3928
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | AS110387757
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------