Provider Demographics
NPI:1114689585
Name:AGING GRACEFUL CARE LLC
Entity Type:Organization
Organization Name:AGING GRACEFUL CARE LLC
Other - Org Name:AGING GRACEFUL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOSHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COBB
Authorized Official - Suffix:
Authorized Official - Credentials:PTA,LMT
Authorized Official - Phone:217-454-9645
Mailing Address - Street 1:2610 S FORREST GREEN DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5411
Mailing Address - Country:US
Mailing Address - Phone:217-454-9645
Mailing Address - Fax:
Practice Address - Street 1:5160 HICKORY POINT FRONTAGE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-9778
Practice Address - Country:US
Practice Address - Phone:217-247-3120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care