MEDICARE: GRACEFULLY AGING LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174088827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEFULLY AGING LLC

Provider Business Mailing Address
First Line	:	1837 LOCHSHYRE LOOP
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761-9160
Country	:	US
Telephone Number	:	407-744-9043
Fax Number	:

Provider Business Practice Location Address
First Line	:	1837 LOCHSHYRE LOOP
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761-9160
Country	:	US
Telephone Number	:	407-744-9043
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	NAKIA STARKER
Credential	:
Telephone Number	:	407-844-5840

Provider Enumeration Date	:	02/06/2019
Last Update Date	:	06/02/2021

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