Provider Demographics
NPI:1962889147
Name:AMAZING GRACE PCA, LLC
Entity type:Organization
Organization Name:AMAZING GRACE PCA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DELPHENIA
Authorized Official - Middle Name:MONTGOMERY
Authorized Official - Last Name:LODIONG
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:504-261-7602
Mailing Address - Street 1:413 QUEEN ANNE DR
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70460-8439
Mailing Address - Country:US
Mailing Address - Phone:504-261-7602
Mailing Address - Fax:504-248-5302
Practice Address - Street 1:7240 CROWDER BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-1922
Practice Address - Country:US
Practice Address - Phone:504-309-8190
Practice Address - Fax:504-309-8196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-27
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203782320251G00000X, 253Z00000X
LAHC0007481253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1026042Medicaid
LA1031305Medicaid