Healthcare Provider Details

I. General information

NPI: 1477098531
Provider Name (Legal Business Name): GRACE THEIOS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 COUNTY ROAD 105
CARTHAGE MO
64836
US

IV. Provider business mailing address

6031 COUNTY ROAD 105
CARTHAGE MO
64836
US

V. Phone/Fax

Practice location:
  • Phone: 417-317-4434
  • Fax:
Mailing address:
  • Phone: 417-317-4434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateMO

VIII. Authorized Official

Name: IGOR GONZALEZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 417-392-1297