1760916407 NPI number — GRACE HOME ASSISTED LIVING 1

Table of content: (NPI 1760916407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760916407 NPI number — GRACE HOME ASSISTED LIVING 1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACE HOME ASSISTED LIVING 1
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:
GRACE HOME ASSISTED LIVING 2
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:
1760916407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2261 S QUAIL HOLLOW DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85710-7982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-312-0225
Provider Business Mailing Address Fax Number:
520-207-2223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 S QUAIL HOLLOW DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85710-7986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-312-0225
Provider Business Practice Location Address Fax Number:
520-207-2223
Provider Enumeration Date:
04/19/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BRAGA
Authorized Official First Name:
NORMA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
520-312-0225

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  AL6571H , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320700000X , with the licence number: AL6571H , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320900000X , with the licence number: AL6571-H , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X , with the licence number: AL7454H , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747A0650X , with the licence number: AL7454-H , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 95188554F13239 . This is a "MEDICAID" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0301305850 . This is a "AARP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 85808889 . This is a "MEDICAID AND MUTUAL OF OMAHA" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 00416712603 . This is a "TRICARE PRIME INSURANCE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 783517401 . This is a "MEDICAID AND AARP" identifier . This identifiers is of the category "OTHER".




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