Provider Demographics
NPI:1245214873
Name:GRACE INDEPENDENT HOME CARE, INC.
Entity Type:Organization
Organization Name:GRACE INDEPENDENT HOME CARE, INC.
Other - Org Name:ONESOURCE HOME CARE INC
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-248-2530
Mailing Address - Street 1:4002 TECHNOLOGY CTR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-2697
Mailing Address - Country:US
Mailing Address - Phone:903-248-2530
Mailing Address - Fax:903-248-2538
Practice Address - Street 1:4002 TECHNOLOGY CTR
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605
Practice Address - Country:US
Practice Address - Phone:903-248-2530
Practice Address - Fax:903-248-2538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX007854251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104147339OtherNPI
TX153380401Medicaid
TXHH565HOtherBLUE CROSSBLUE SHIELD