Healthcare Provider Details

I. General information

NPI: 1205900917
Provider Name (Legal Business Name): GRACEWORKS ENHANCED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11651 WALNUT ST
CINCINNATI OH
45246-3046
US

IV. Provider business mailing address

11370 SPRINGFIELD PIKE
CINCINNATI OH
45246-4202
US

V. Phone/Fax

Practice location:
  • Phone: 513-671-2654
  • Fax: 513-671-1293
Mailing address:
  • Phone: 513-612-6500
  • Fax: 513-612-6545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number3112143
License Number StateOH

VIII. Authorized Official

Name: MR. MICHAEL W ALLEN
Title or Position: VICE PRESIDENT, FINANCE & FACILITIE
Credential:
Phone: 937-436-6885