Provider Demographics
NPI:1851019210
Name:GRACE OF ROSA LLC
Entity Type:Organization
Organization Name:GRACE OF ROSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO-NURSE
Authorized Official - Prefix:
Authorized Official - First Name:KRYSTAL
Authorized Official - Middle Name:JANAE
Authorized Official - Last Name:BLUNT
Authorized Official - Suffix:
Authorized Official - Credentials:LVN/LPN
Authorized Official - Phone:619-874-3443
Mailing Address - Street 1:27317 MANZANITA LN APT 205
Mailing Address - Street 2:
Mailing Address - City:CANYON COUNTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91387-5114
Mailing Address - Country:US
Mailing Address - Phone:619-874-3443
Mailing Address - Fax:
Practice Address - Street 1:27317 MANZANITA LN APT 205
Practice Address - Street 2:
Practice Address - City:CANYON COUNTRY
Practice Address - State:CA
Practice Address - Zip Code:91387-5114
Practice Address - Country:US
Practice Address - Phone:619-874-3443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA718992OtherBOARD OF VOCATIONAL NURSING AND PSYCHIATRIC TECHNICIANS
AZ246816OtherARIZONA STATE BOARD OF NURSING