MEDICARE: GRACEWORKS ENAHNCED LIVING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1679160725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEWORKS ENAHNCED LIVING

Provider Business Mailing Address
First Line	:	11370 SPRINGFIELD PIKE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45246-4202
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3040 QUEEN CITY AVE
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2489
Country	:	US
Telephone Number	:	513-954-0906
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT, FINANCE & FACILITIE
Name	:	MR. MICHAEL W ALLEN
Credential	:
Telephone Number	:	937-436-6885

Provider Enumeration Date	:	12/23/2020
Last Update Date	:	12/23/2020

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