Provider Demographics
NPI:1831876671
Name:HEART OF GRACE HOME CARE LLC
Entity type:Organization
Organization Name:HEART OF GRACE HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOOTEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:601-564-1309
Mailing Address - Street 1:813 HIGHWAY 35 S
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-4031
Mailing Address - Country:US
Mailing Address - Phone:601-564-1309
Mailing Address - Fax:601-287-8230
Practice Address - Street 1:813 HIGHWAY 35 S
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-4031
Practice Address - Country:US
Practice Address - Phone:601-564-1309
Practice Address - Fax:601-287-8230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care