Provider Demographics
NPI: | 1720494578 |
---|---|
Name: | A GRACEFUL WAY, LLC |
Entity Type: | Organization |
Organization Name: | A GRACEFUL WAY, LLC |
Other - Org Name: | A GRACEFUL WAY IN-HOME CARE |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER/CEO |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | RYAN |
Authorized Official - Middle Name: | SULLIVAN |
Authorized Official - Last Name: | REEDOM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 310-857-9644 |
Mailing Address - Street 1: | 6307 5TH AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | LOS ANGELES |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90043-4257 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 310-857-9644 |
Mailing Address - Fax: | 323-753-6645 |
Practice Address - Street 1: | 6307 5TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | LOS ANGELES |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90043-4257 |
Practice Address - Country: | US |
Practice Address - Phone: | 310-857-9644 |
Practice Address - Fax: | 323-753-6645 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2014-07-01 |
Last Update Date: | 2014-07-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 201317810050 | 253Z00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 253Z00000X | Agencies | In Home Supportive Care |