Provider Demographics
NPI:1285098590
Name:WINN-FUL GRACE HOMECARE SERVICE INC
Entity type:Organization
Organization Name:WINN-FUL GRACE HOMECARE SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WINNIFRED
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-812-7724
Mailing Address - Street 1:1104 BARTOW RD APT H85
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-5850
Mailing Address - Country:US
Mailing Address - Phone:863-812-7724
Mailing Address - Fax:
Practice Address - Street 1:1104 BARTOW RD APT H85
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5850
Practice Address - Country:US
Practice Address - Phone:863-812-7724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010465800Medicaid