Provider Demographics
NPI:1811617863
Name:BEAUTIFULLY GRACED LLC
Entity type:Organization
Organization Name:BEAUTIFULLY GRACED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:JERNIGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-220-0862
Mailing Address - Street 1:2155 PALM BAY RD NE STE 7
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905-2907
Mailing Address - Country:US
Mailing Address - Phone:321-220-0862
Mailing Address - Fax:
Practice Address - Street 1:2155 PALM BAY RD NE STE 7
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2907
Practice Address - Country:US
Practice Address - Phone:321-220-0862
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
Yes171400000XOther Service ProvidersHealth & Wellness CoachGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCL1284556OtherCOSMETOLOGY LICENSE