Provider Demographics
NPI:1275971095
Name:AMAZING GRACE HOME HEALTH CARE LLC
Entity Type:Organization
Organization Name:AMAZING GRACE HOME HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:NICCOYA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-606-3170
Mailing Address - Street 1:3940 AIRLINE BLVD
Mailing Address - Street 2:118
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3329
Mailing Address - Country:US
Mailing Address - Phone:757-606-3170
Mailing Address - Fax:757-606-3993
Practice Address - Street 1:3940 AIRLINE BLVD
Practice Address - Street 2:118
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3329
Practice Address - Country:US
Practice Address - Phone:757-606-3170
Practice Address - Fax:757-606-3993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-14
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHCO141040251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health