MEDICARE: AMAZING GRACE HOME CARE, 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	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1326846650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING GRACE HOME CARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 152
Second Line	:
City	:	SPIRIT LAKE
State	:	ID
Zip	:	83869-0152
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7128 W HOODOO PL
Second Line	:
City	:	SPIRIT LAKE
State	:	ID
Zip	:	83869
Country	:	US
Telephone Number	:	208-290-7094
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHANNON KIEHN
Credential	:
Telephone Number	:	208-290-7094

Provider Enumeration Date	:	03/04/2025
Last Update Date	:	03/04/2025

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