Provider Demographics
NPI:1073182424
Name:ABUNDANT GRACE HOME CARE LLC
Entity Type:Organization
Organization Name:ABUNDANT GRACE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO/DON
Authorized Official - Prefix:
Authorized Official - First Name:KIERRA
Authorized Official - Middle Name:DEGALE
Authorized Official - Last Name:YOUNGBLOOD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:318-773-4845
Mailing Address - Street 1:1651 E 70TH ST # 264
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5115
Mailing Address - Country:US
Mailing Address - Phone:318-773-4845
Mailing Address - Fax:318-716-1024
Practice Address - Street 1:9051 MANSFIELD RD STE B7
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-2666
Practice Address - Country:US
Practice Address - Phone:318-773-4845
Practice Address - Fax:318-716-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health