1194177097 NPI number — GRACE ASSISTED LIVING, LLC

Table of content: (NPI 1194177097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194177097 NPI number — GRACE ASSISTED LIVING, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE ASSISTED LIVING, LLC
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:
Provider Other Organization Name Type Code:
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:
1194177097
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16658 SAN EDMUNDO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PUNTA GORDA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33955-4040
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-220-6106
Provider Business Mailing Address Fax Number:
941-621-4975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22091 PEACHLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT CHARLOTTE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33954-3352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
941-766-7178
Provider Business Practice Location Address Fax Number:
941-621-4975
Provider Enumeration Date:
07/05/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
COOPER
Authorized Official First Name:
GRACE
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER/ADMINISTRATOR
Authorized Official Telephone Number:
941-766-7178

Provider Taxonomy Codes

  • Taxonomy code: 3104A0625X , with the licence number:  AL12849 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: AL12849 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 017993600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".