Provider Demographics
NPI:1972373272
Name:AMAZING GRACE COMMUNITY SUPPORT LLC
Entity type:Organization
Organization Name:AMAZING GRACE COMMUNITY SUPPORT LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:IFUNANYA
Authorized Official - Last Name:OJUKWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-507-3173
Mailing Address - Street 1:186 KETTLEBROOK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2672
Mailing Address - Country:US
Mailing Address - Phone:562-507-3173
Mailing Address - Fax:
Practice Address - Street 1:186 KETTLEBROOK DR
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2672
Practice Address - Country:US
Practice Address - Phone:562-507-3173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services