MEDICARE: GRACELIGHT COMMUNITY HEALTH

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	261QF0400X	Federally Qualified Health Center (FQHC)	960001125	CA

General Provider Information

NPI Number	:	1801967062
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACELIGHT COMMUNITY HEALTH

Provider Business Mailing Address
First Line	:	4816 E 3RD ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90022-1602
Country	:	US
Telephone Number	:	323-780-4510
Fax Number	:	323-981-1662

Provider Business Practice Location Address
First Line	:	4448 YORK BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-3328
Country	:	US
Telephone Number	:	323-344-5233
Fax Number	:	323-344-5237

Authorized Official
Title or Position	:	PRESIDENT & CEO
Name	:	MRS. ELOISA PERARD
Credential	:
Telephone Number	:	323-669-4321

Provider Enumeration Date	:	11/10/2006
Last Update Date	:	06/27/2024

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