Healthcare Provider Details

I. General information

NPI: 1144199688
Provider Name (Legal Business Name): GIFT OF GRACE RESIDENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2025
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 W 46TH ST
LOS ANGELES CA
90037-2722
US

IV. Provider business mailing address

611 WILSHIRE BLVD STE 900
LOS ANGELES CA
90017-2905
US

V. Phone/Fax

Practice location:
  • Phone: 323-400-9462
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KENISHA FANIEL
Title or Position: ADMINISTRATOR
Credential:
Phone: 323-400-9462