Provider Demographics
NPI:1639368129
Name:HOUSE OF GRACE PERSONAL CARE HOME
Entity Type:Organization
Organization Name:HOUSE OF GRACE PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:P
Authorized Official - Last Name:STFLEUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-549-0877
Mailing Address - Street 1:80 JENNA LN
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-6645
Mailing Address - Country:US
Mailing Address - Phone:404-549-0877
Mailing Address - Fax:
Practice Address - Street 1:80 JENNA LN
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30016-6645
Practice Address - Country:US
Practice Address - Phone:404-549-0877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home