Provider Demographics
NPI:1083450498
Name:AMAZING GRACE PCA LLC
Entity type:Organization
Organization Name:AMAZING GRACE PCA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DELPHENIA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LODIONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:907-342-5608
Mailing Address - Street 1:182 ELLERSLIE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5917
Mailing Address - Country:US
Mailing Address - Phone:907-342-5608
Mailing Address - Fax:
Practice Address - Street 1:182 ELLERSLIE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5917
Practice Address - Country:US
Practice Address - Phone:907-342-5608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health