=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962269712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACEFUL COMFORT HOME CARE SERVICE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2024
-----------------------------------------------------
Last Update Date | 02/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4780 RIVERDALE RD STE 16
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38141-8509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-258-0468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 770 GARDNER RD
-----------------------------------------------------
City | HOLLY SPRINGS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38635-8376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-258-0468
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESSICA SANDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-258-0468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------