MEDICARE: AMAZING GACE ASSISTED LIVING HOME

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	310400000X	Assisted Living Facility	AL12171	FL

General Provider Information

NPI Number	:	1497097638
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING GACE ASSISTED LIVING HOME

Provider Business Mailing Address
First Line	:	2685 CARAMBOLA RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-5106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2685 CARAMBOLA RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-5106
Country	:	US
Telephone Number	:	561-357-9559
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	DEBORAH LYTLE
Credential	:
Telephone Number	:	561-818-5790

Provider Enumeration Date	:	03/26/2013
Last Update Date	:	03/26/2013

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