Provider Demographics
NPI:1891381075
Name:GRACEFULLY YOURS
Entity Type:Organization
Organization Name:GRACEFULLY YOURS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:318-464-1989
Mailing Address - Street 1:959 TOWN NORTH DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-2835
Mailing Address - Country:US
Mailing Address - Phone:318-464-1989
Mailing Address - Fax:
Practice Address - Street 1:959 TOWN NORTH DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-2835
Practice Address - Country:US
Practice Address - Phone:318-464-1989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000000OtherN/A