1790141281 NPI number — GRACIOUS HAVEN HEALTHCARE LLC

Table of content: (NPI 1790141281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790141281 NPI number — GRACIOUS HAVEN HEALTHCARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRACIOUS HAVEN HEALTHCARE 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:
1790141281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/13/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 64636
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:
85728-4636
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-975-3119
Provider Business Mailing Address Fax Number:
520-844-1522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3843 E PRESIDIO RD
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:
85716-1736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-975-3119
Provider Business Practice Location Address Fax Number:
520-844-1522
Provider Enumeration Date:
01/13/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAGNON
Authorized Official First Name:
CHRISTIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
520-975-3119

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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