Healthcare Provider Details

I. General information

NPI: 1457995813
Provider Name (Legal Business Name): GRACE WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SOUTHERN AVE
MESA AZ
85206-2569
US

IV. Provider business mailing address

1024 W OWENS AVE STE B
LAS VEGAS NV
89106-2520
US

V. Phone/Fax

Practice location:
  • Phone: 702-937-7789
  • Fax:
Mailing address:
  • Phone: 702-937-7789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JOHNA DEAN
Title or Position: OWNER
Credential:
Phone: 702-937-7789