Provider Demographics
NPI:1033738554
Name:AGEGRACE, INC.
Entity Type:Organization
Organization Name:AGEGRACE, INC.
Other - Org Name:JAO COMPANIES
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:QDDS
Authorized Official - Phone:612-707-8121
Mailing Address - Street 1:PO BOX 28041
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-0041
Mailing Address - Country:US
Mailing Address - Phone:612-707-8121
Mailing Address - Fax:
Practice Address - Street 1:635 PHALEN BLVD APT 401
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5308
Practice Address - Country:US
Practice Address - Phone:612-707-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-14
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNM52298200Medicaid