Provider Demographics
NPI:1861548703
Name:AMAZING GRACE HOME HEALTHCARE LLC
Entity type:Organization
Organization Name:AMAZING GRACE HOME HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LATRISHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUNTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-405-3377
Mailing Address - Street 1:1801 N TRYON ST
Mailing Address - Street 2:STE B 329
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2793
Mailing Address - Country:US
Mailing Address - Phone:704-405-3377
Mailing Address - Fax:704-405-3379
Practice Address - Street 1:1801 N TRYON ST
Practice Address - Street 2:STE B 329
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2793
Practice Address - Country:US
Practice Address - Phone:704-405-3377
Practice Address - Fax:704-405-3379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601608Medicaid