Provider Demographics
NPI:1568993319
Name:AMAZING GRACE ASSISTED LIVING SERVICES LLC
Entity Type:Organization
Organization Name:AMAZING GRACE ASSISTED LIVING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MONTRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:THORNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-757-6932
Mailing Address - Street 1:14812 STRATFORD CT
Mailing Address - Street 2:APT B
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-1962
Mailing Address - Country:US
Mailing Address - Phone:314-757-6932
Mailing Address - Fax:
Practice Address - Street 1:14812 STRATFORD CT
Practice Address - Street 2:APT B
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-1962
Practice Address - Country:US
Practice Address - Phone:314-757-6932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-23
Last Update Date:2017-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health