Provider Demographics
NPI:1912190414
Name:AMAZING GRACE SYSTEMS HOME HEALTH,LLC
Entity Type:Organization
Organization Name:AMAZING GRACE SYSTEMS HOME HEALTH,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ADEMOLA
Authorized Official - Last Name:OYETUNDE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE LVN
Authorized Official - Phone:915-587-4968
Mailing Address - Street 1:921 LAS AVES PL
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79912-7326
Mailing Address - Country:US
Mailing Address - Phone:915-587-4968
Mailing Address - Fax:915-581-0170
Practice Address - Street 1:921 LAS AVES PL
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79912-7326
Practice Address - Country:US
Practice Address - Phone:915-587-4968
Practice Address - Fax:915-581-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX011021251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health