MEDICARE: GRACE CARE SER 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
2	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619331451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE CARE SER LLC

Provider Business Mailing Address
First Line	:	395 E CENTRAL AVE
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-3047
Country	:	US
Telephone Number	:	863-585-0147
Fax Number	:	863-875-5348

Provider Business Practice Location Address
First Line	:	395 E CENTRAL AVE
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33880-3047
Country	:	US
Telephone Number	:	863-585-0147
Fax Number	:	863-875-5348

Authorized Official
Title or Position	:	OWNER
Name	:	SHANELL S CODY
Credential	:
Telephone Number	:	863-585-0147

Provider Enumeration Date	:	04/07/2016
Last Update Date	:	06/29/2023

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