Healthcare Provider Details

I. General information

NPI: 1265020697
Provider Name (Legal Business Name): GRACEWORKS ENHANCED LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2020
Last Update Date: 12/31/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 FREDERICKSBURG DR
DAYTON OH
45415-2649
US

IV. Provider business mailing address

11370 SPRINGFIELD PIKE
CINCINNATI OH
45246-4202
US

V. Phone/Fax

Practice location:
  • Phone: 937-331-8141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

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