Provider Demographics
NPI:1104397397
Name:EXTENDED GRACE HOME CARE SERVICES LLC
Entity Type:Organization
Organization Name:EXTENDED GRACE HOME CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YALESIA
Authorized Official - Middle Name:N
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-453-8981
Mailing Address - Street 1:5918 OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH RIDGEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44039-1832
Mailing Address - Country:US
Mailing Address - Phone:440-412-9279
Mailing Address - Fax:440-848-8894
Practice Address - Street 1:1905 N RIDGE RD E STE D
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44055-3344
Practice Address - Country:US
Practice Address - Phone:440-412-9279
Practice Address - Fax:440-848-8894
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0275647Medicaid