Provider Demographics
NPI:1356834311
Name:AMAZING GRACE ASSISTED LIVING HOME III LLC
Entity Type:Organization
Organization Name:AMAZING GRACE ASSISTED LIVING HOME III LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LYTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-818-5790
Mailing Address - Street 1:1851 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:LAKE CLARKE SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33406-5231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1851 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:LAKE CLARKE SHORES
Practice Address - State:FL
Practice Address - Zip Code:33406-5231
Practice Address - Country:US
Practice Address - Phone:561-642-4221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12836310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility