Provider Demographics
NPI:1861926867
Name:AGING GRACEFULLY LLC
Entity type:Organization
Organization Name:AGING GRACEFULLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENAE
Authorized Official - Middle Name:
Authorized Official - Last Name:TYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-316-6719
Mailing Address - Street 1:2013 N ARMISTEAD AVE
Mailing Address - Street 2:APT D18
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-3400
Mailing Address - Country:US
Mailing Address - Phone:757-316-6719
Mailing Address - Fax:
Practice Address - Street 1:2013 N ARMISTEAD AVE
Practice Address - Street 2:APT D18
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3400
Practice Address - Country:US
Practice Address - Phone:757-316-6719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA125633311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home