Provider Demographics
NPI:1508575895
Name:GRACE COVENANT SERVICES, LLC
Entity Type:Organization
Organization Name:GRACE COVENANT SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:REGISTERED NURSE
Authorized Official - Phone:662-580-0635
Mailing Address - Street 1:1600 E REED RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703-7229
Mailing Address - Country:US
Mailing Address - Phone:662-580-0653
Mailing Address - Fax:662-580-0569
Practice Address - Street 1:1600 E REED RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703-7229
Practice Address - Country:US
Practice Address - Phone:662-580-0653
Practice Address - Fax:662-580-0569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-16
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care