Healthcare Provider Details

I. General information

NPI: 1104745058
Provider Name (Legal Business Name): GRACIE'S ADULT CARE HOME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 CARNELIA ST SE
SALEM OR
97306-2077
US

IV. Provider business mailing address

4841 RANGER AVE NE
SALEM OR
97305-4141
US

V. Phone/Fax

Practice location:
  • Phone: 971-239-2000
  • Fax: 503-339-7927
Mailing address:
  • Phone: 971-239-2000
  • Fax: 503-339-7929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. LISA ELIZABETH BRUNDIDGE
Title or Position: OWNER
Credential:
Phone: 971-239-2000