Provider Demographics
NPI:1730644253
Name:GRACE COVENANT HOMES LLC
Entity Type:Organization
Organization Name:GRACE COVENANT HOMES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ICILDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-252-6739
Mailing Address - Street 1:3409 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-8120
Mailing Address - Country:US
Mailing Address - Phone:248-252-6739
Mailing Address - Fax:254-393-0457
Practice Address - Street 1:3409 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-8120
Practice Address - Country:US
Practice Address - Phone:248-252-6739
Practice Address - Fax:254-393-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-08
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care