Provider Demographics
NPI:1669673521
Name:GRACIOUS AGE LLC
Entity Type:Organization
Organization Name:GRACIOUS AGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOCELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLOS
Authorized Official - Suffix:
Authorized Official - Credentials:BSN RN
Authorized Official - Phone:407-323-9914
Mailing Address - Street 1:1401 S MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-3400
Mailing Address - Country:US
Mailing Address - Phone:407-323-9914
Mailing Address - Fax:407-323-6310
Practice Address - Street 1:1401 S MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-3400
Practice Address - Country:US
Practice Address - Phone:407-323-9914
Practice Address - Fax:407-323-6310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10274310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL689602200Medicaid
FL142508100Medicaid