=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760199806
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE & MERCY PERSONAL CARE PROVIDER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2022
-----------------------------------------------------
Last Update Date | 04/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 GWENN RAY DR
-----------------------------------------------------
City | EUPORA
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39744-3403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-258-1018
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24224 MS HIGHWAY 15
-----------------------------------------------------
City | MATHISTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39752-6876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-263-3194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | MRS. OLEAN DENISE PITTMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 662-262-3194
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------