Provider Demographics
NPI:1902121809
Name:GRACE HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:GRACE HEALTHCARE SERVICES INC
Other - Org Name:MCDOUGLE PERSONAL CARE HOME INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:E
Authorized Official - Last Name:MCDOUGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-269-8880
Mailing Address - Street 1:1010 SLATER STREET
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31601
Mailing Address - Country:US
Mailing Address - Phone:229-469-4052
Mailing Address - Fax:229-588-4039
Practice Address - Street 1:1010 SLATER STREET
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31601
Practice Address - Country:US
Practice Address - Phone:229-469-4052
Practice Address - Fax:229-588-4039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-02
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA372083530A385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA372083530AOtherPROVIDER ID NUMBER
GA092-01-106-1OtherPERSONAL CARE PERMIT NO
092011061Medicare PIN