Healthcare Provider Details

I. General information

NPI: 1316070139
Provider Name (Legal Business Name): GRACE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7511 N AVA AVE
KANSAS CITY MO
64151-4242
US

IV. Provider business mailing address

7511 N AVA AVE
KANSAS CITY MO
64151-4242
US

V. Phone/Fax

Practice location:
  • Phone: 816-587-9224
  • Fax:
Mailing address:
  • Phone: 816-587-9224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number17639733
License Number StateMO

VIII. Authorized Official

Name: MRS. TERESA LYNN GRACE
Title or Position: OWNER
Credential:
Phone: 816-587-9224