Provider Demographics
NPI:1194012799
Name:DYNAMIC GRACE HOME HEALTH CARE SERVICES,INC
Entity Type:Organization
Organization Name:DYNAMIC GRACE HOME HEALTH CARE SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:O
Authorized Official - Last Name:OTIEDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-703-0658
Mailing Address - Street 1:6510 TAMRA DR
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84084-5733
Mailing Address - Country:US
Mailing Address - Phone:801-703-0658
Mailing Address - Fax:
Practice Address - Street 1:6510 TAMRA DR
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84084-5733
Practice Address - Country:US
Practice Address - Phone:801-703-0658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2011-HHA-102739251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health