Healthcare Provider Details

I. General information

NPI: 1902661457
Provider Name (Legal Business Name): GRACE FAMILY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2024
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E MADISON ST STE 100
PHOENIX AZ
85034-2225
US

IV. Provider business mailing address

920 E MADISON ST STE 100
PHOENIX AZ
85034-2225
US

V. Phone/Fax

Practice location:
  • Phone: 480-272-7723
  • Fax:
Mailing address:
  • Phone: 480-272-7723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DORRENDA SMITH
Title or Position: DIRECTOR
Credential:
Phone: 602-628-0601