Provider Demographics
NPI:1497635338
Name:GRACE FRIENDSHIP HOME LLC
Entity type:Organization
Organization Name:GRACE FRIENDSHIP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRIETTA
Authorized Official - Middle Name:G
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-401-2806
Mailing Address - Street 1:2925 SW BOXWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6966
Mailing Address - Country:US
Mailing Address - Phone:954-401-2806
Mailing Address - Fax:954-401-2806
Practice Address - Street 1:4736 NW 5TH AVE
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-2563
Practice Address - Country:US
Practice Address - Phone:954-401-2806
Practice Address - Fax:954-401-2806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-03
Last Update Date:2025-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Single Specialty