MEDICARE: PEARL GRACE 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1437092731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEARL GRACE CARE LLC

Provider Business Mailing Address
First Line	:	648 TIMBER BAY CIR E
Second Line	:
City	:	OLDSMAR
State	:	FL
Zip	:	34677-4310
Country	:	US
Telephone Number	:	727-641-9681
Fax Number	:

Provider Business Practice Location Address
First Line	:	648 TIMBER BAY CIR E
Second Line	:
City	:	OLDSMAR
State	:	FL
Zip	:	34677-4310
Country	:	US
Telephone Number	:	727-641-9681
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TAQUISHA MCCLUSTER
Credential	:
Telephone Number	:	727-641-9681

Provider Enumeration Date	:	04/11/2026
Last Update Date	:	04/11/2026

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