Provider Demographics
NPI:1659816726
Name:AMAZING GRACE HOME HEALTH LLC
Entity Type:Organization
Organization Name:AMAZING GRACE HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTR
Authorized Official - Prefix:MS
Authorized Official - First Name:AVA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-458-6727
Mailing Address - Street 1:3159 FEE FEE RD
Mailing Address - Street 2:SUITE 221
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-3299
Mailing Address - Country:US
Mailing Address - Phone:314-497-7518
Mailing Address - Fax:
Practice Address - Street 1:3159 FEE FEE RD
Practice Address - Street 2:SUITE 221
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-3299
Practice Address - Country:US
Practice Address - Phone:314-497-7518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-28
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health