Provider Demographics
NPI:1316121742
Name:AMAZING GRACE RESIDENTIAL SERVICES AGENCY
Entity type:Organization
Organization Name:AMAZING GRACE RESIDENTIAL SERVICES AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:O
Authorized Official - Last Name:LANLOKUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-497-4117
Mailing Address - Street 1:8645 VINTAGE EARTH PATH
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20723-5880
Mailing Address - Country:US
Mailing Address - Phone:301-497-4117
Mailing Address - Fax:
Practice Address - Street 1:8645 VINTAGE EARTH PATH
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20723-5880
Practice Address - Country:US
Practice Address - Phone:301-497-4117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2546251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health