1508930207 NPI number — GRACEWORKS ENHANCED LIVING

Table of content: (NPI 1508930207)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508930207 NPI number — GRACEWORKS ENHANCED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACEWORKS ENHANCED LIVING
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
VALLEY HOME
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508930207
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11370 SPRINGFIELD PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45246-4202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-612-6500
Provider Business Mailing Address Fax Number:
513-612-6545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3731 ISABELLA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45209-2301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-631-1690
Provider Business Practice Location Address Fax Number:
513-631-6633
Provider Enumeration Date:
11/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
W
Authorized Official Title or Position:
VICE PRESIDENT, FINANCE & FACILITIE
Authorized Official Telephone Number:
937-436-6885

Provider Taxonomy Codes

  • Taxonomy code: 320600000X , with the licence number:  3111939 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0615070 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".