Provider Demographics
NPI:1033557095
Name:GRACEFUL AGING LLC
Entity Type:Organization
Organization Name:GRACEFUL AGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ADEYINKA
Authorized Official - Middle Name:T
Authorized Official - Last Name:ADEGBENLE
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:917-209-6283
Mailing Address - Street 1:2620 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-3648
Mailing Address - Country:US
Mailing Address - Phone:516-377-0057
Mailing Address - Fax:516-377-0057
Practice Address - Street 1:881 MERRICK RD
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-3331
Practice Address - Country:US
Practice Address - Phone:917-209-6283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care