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General NPI Number Information
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NPI Number | 1689984379
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Entity Type | Organization
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Legal Business Name | AMAZING GRACE PCH
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Dates
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Enumeration Date | 10/14/2010
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Last Update Date | 10/14/2010
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Provider Practice Location Address
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Address Line | 1307 CABANA CT
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City | AUGUSTA
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State | GA
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Zip | 30909-2419
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Country | US
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Telephone | 706-834-8106
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Fax |
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Provider Business Mailing Address
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Address Line | 4570 PINTAIL CT
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City | MARTINEZ
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State | GA
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Zip | 30907-8872
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Country | US
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Telephone | 706-834-8106
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CHANDRA TOMIKO JONES
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Credential |
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Telephone | 706-834-8106
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 121014381
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License Number State | GA
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