Provider Demographics
NPI:1376081810
Name:AMAZING GRACE CARE HOMES, INCESIDENT
Entity Type:Organization
Organization Name:AMAZING GRACE CARE HOMES, INCESIDENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERRI
Authorized Official - Middle Name:M
Authorized Official - Last Name:JEMISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-999-8159
Mailing Address - Street 1:6995 SW NYBERG ST
Mailing Address - Street 2:SUITE X201
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-7455
Mailing Address - Country:US
Mailing Address - Phone:503-999-8159
Mailing Address - Fax:
Practice Address - Street 1:1205 BARNES AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-1539
Practice Address - Country:US
Practice Address - Phone:503-999-8159
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-04
Last Update Date:2017-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5114823104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500500049OtherMARION COUNTY MENTAL HEALTH AFC PROVIDER