Provider Demographics
NPI:1962164426
Name:HIS GRACE AND MERCY HOME CARE LLC
Entity type:Organization
Organization Name:HIS GRACE AND MERCY HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSEBORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-819-7540
Mailing Address - Street 1:3125 EASTWAY DR STE 213
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5643
Mailing Address - Country:US
Mailing Address - Phone:980-819-7540
Mailing Address - Fax:
Practice Address - Street 1:3125 EASTWAY DR STE 213
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5643
Practice Address - Country:US
Practice Address - Phone:980-819-7540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC210776Medicaid