Provider Demographics
NPI:1134709561
Name:LOVE OF GRACE PNCC SERVICES LLC
Entity type:Organization
Organization Name:LOVE OF GRACE PNCC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:800-284-5316
Mailing Address - Street 1:3925 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2334
Mailing Address - Country:US
Mailing Address - Phone:414-517-8405
Mailing Address - Fax:
Practice Address - Street 1:3925 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2334
Practice Address - Country:US
Practice Address - Phone:414-517-8405
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management