Healthcare Provider Details

I. General information

NPI: 1740835743
Provider Name (Legal Business Name): GRACELIGHT COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2019
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 LOMA DR STE 202
LOS ANGELES CA
90017-1103
US

IV. Provider business mailing address

4816 E 3RD ST
LOS ANGELES CA
90022-1602
US

V. Phone/Fax

Practice location:
  • Phone: 323-635-1140
  • Fax:
Mailing address:
  • Phone: 323-780-4510
  • Fax: 323-981-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ELOISA PERARD
Title or Position: PRESIDENT & CEO
Credential:
Phone: 323-669-4321