Provider Demographics
NPI:1598013542
Name:GRACIOUS CARE AGENCY LLC
Entity Type:Organization
Organization Name:GRACIOUS CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PIERRE
Authorized Official - Middle Name:
Authorized Official - Last Name:OMELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:781-929-2273
Mailing Address - Street 1:49B ERLANGER BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11703-1106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5910
Practice Address - Country:US
Practice Address - Phone:718-929-0919
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-23
Last Update Date:2012-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health