MEDICARE: GRACELAND HOME HEALTH CARE &SUPPORTED LIVING

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	201204700701	OH

General Provider Information

NPI Number	:	1427314905
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACELAND HOME HEALTH CARE &SUPPORTED LIVING

Provider Business Mailing Address
First Line	:	1756 STILTON AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-4574
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1756 STILTON AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43228-4574
Country	:	US
Telephone Number	:	614-772-8700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RUGIATOU JALLOW
Credential	:
Telephone Number	:	614-772-8700

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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