Provider Demographics
NPI:1215395900
Name:GRACE SUPPORTIVE LIVING SERVICES LLC
Entity Type:Organization
Organization Name:GRACE SUPPORTIVE LIVING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSE NURSE
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:770-984-5388
Mailing Address - Street 1:3350 RIVERWOOD PKWY SE
Mailing Address - Street 2:1900
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-6401
Mailing Address - Country:US
Mailing Address - Phone:770-984-5388
Mailing Address - Fax:
Practice Address - Street 1:3350 RIVERWOOD PKWY SE
Practice Address - Street 2:1900
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-6401
Practice Address - Country:US
Practice Address - Phone:770-984-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-09
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
GALPN0089404253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1154604015OtherMEDICARE MEDICAID