Provider Demographics
NPI:1104525393
Name:AMAZING GRACE RESIDENCIAL SERVICES LLC
Entity type:Organization
Organization Name:AMAZING GRACE RESIDENCIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROLANDE
Authorized Official - Middle Name:
Authorized Official - Last Name:TIEMENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-807-7950
Mailing Address - Street 1:522 SMILEY AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-2220
Mailing Address - Country:US
Mailing Address - Phone:513-807-7950
Mailing Address - Fax:
Practice Address - Street 1:522 SMILEY AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-2220
Practice Address - Country:US
Practice Address - Phone:513-807-7950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Other0
OH0OtherN