Provider Demographics
NPI:1174088827
Name:GRACEFULLY AGING LLC
Entity type:Organization
Organization Name:GRACEFULLY AGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NAKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:STARKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-844-5840
Mailing Address - Street 1:1837 LOCHSHYRE LOOP
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-9160
Mailing Address - Country:US
Mailing Address - Phone:407-744-9043
Mailing Address - Fax:
Practice Address - Street 1:1837 LOCHSHYRE LOOP
Practice Address - Street 2:
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-9160
Practice Address - Country:US
Practice Address - Phone:407-744-9043
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACEFULLY AGING LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-06
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1578032967Medicaid