Provider Demographics
NPI:1619012754
Name:AMAZING GRACE REST HOME
Entity Type:Organization
Organization Name:AMAZING GRACE REST HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:EARLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-435-2952
Mailing Address - Street 1:3633 AMAZING GRACE RD
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28090-8407
Mailing Address - Country:US
Mailing Address - Phone:704-435-2952
Mailing Address - Fax:
Practice Address - Street 1:3633 AMAZING GRACE RD
Practice Address - Street 2:
Practice Address - City:LAWNDALE
Practice Address - State:NC
Practice Address - Zip Code:28090-8407
Practice Address - Country:US
Practice Address - Phone:704-435-2952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7802290OtherPROVIDER NUMBER