Provider Demographics
NPI:1073173522
Name:AMAZING GRACE HEALTHCARE,LLC
Entity Type:Organization
Organization Name:AMAZING GRACE HEALTHCARE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BINETTE
Authorized Official - Middle Name:FORZONG
Authorized Official - Last Name:FONGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-390-7313
Mailing Address - Street 1:2306 BRIGHTSEAT RD APT 5
Mailing Address - Street 2:
Mailing Address - City:LANDOVER
Mailing Address - State:MD
Mailing Address - Zip Code:20785-3550
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2306 BRIGHTSEAT RD APT 5
Practice Address - Street 2:
Practice Address - City:LANDOVER
Practice Address - State:MD
Practice Address - Zip Code:20785-3550
Practice Address - Country:US
Practice Address - Phone:202-390-7313
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-17
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities