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General NPI Number Information
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NPI Number | 1720494578
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Entity Type | Organization
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Legal Business Name | A GRACEFUL WAY, LLC
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Dates
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Enumeration Date | 07/01/2014
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Last Update Date | 07/01/2014
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Provider Practice Location Address
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Address Line | 6307 5TH AVE
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City | LOS ANGELES
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State | CA
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Zip | 90043-4257
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Country | US
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Telephone | 310-857-9644
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Fax | 323-753-6645
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Provider Business Mailing Address
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Address Line | 6307 5TH AVE
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City | LOS ANGELES
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State | CA
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Zip | 90043-4257
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Country | US
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Telephone | 310-857-9644
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Fax | 323-753-6645
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MR. RYAN SULLIVAN REEDOM
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Credential |
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Telephone | 310-857-9644
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 201317810050
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License Number State | CA
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