MEDICARE: GRACE DEVELOPMENT CLAN INC.

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	MHL034210	NC

General Provider Information

NPI Number	:	1780724484
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE DEVELOPMENT CLAN INC.

Provider Business Mailing Address
First Line	:	3502 CHERRY ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-3416
Country	:	US
Telephone Number	:	336-480-8369
Fax Number	:	336-721-1176

Provider Business Practice Location Address
First Line	:	3502 CHERRY ST
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27105-3416
Country	:	US
Telephone Number	:	336-480-8369
Fax Number	:	336-721-1176

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. TONYA G BARNES
Credential	:
Telephone Number	:	336-480-8369

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/22/2020

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