MEDICARE: GRACEFUL IN 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1396492237
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEFUL IN HOME CARE, LLC

Provider Business Mailing Address
First Line	:	919 TRUE ST UNIT E2
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1662
Country	:	US
Telephone Number	:	803-451-0152
Fax Number	:	803-451-0073

Provider Business Practice Location Address
First Line	:	919 TRUE ST UNIT E2
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29209-1662
Country	:	US
Telephone Number	:	803-451-0152
Fax Number	:	803-451-0073

Authorized Official
Title or Position	:	OWNER
Name	:	CAROL L JOHNSON
Credential	:
Telephone Number	:	803-476-2108

Provider Enumeration Date	:	03/09/2022
Last Update Date	:	03/09/2022

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