Healthcare Provider Details

I. General information

NPI: 1043733231
Provider Name (Legal Business Name): GRACELAND HOMES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 AMBARELLA STREET
ARLINGTON TX
76002-7600
US

IV. Provider business mailing address

603 AMBARELLA ST
ARLINGTON TX
76002-4505
US

V. Phone/Fax

Practice location:
  • Phone: 817-962-9529
  • Fax:
Mailing address:
  • Phone: 817-962-9529
  • 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 Number
License Number State

VIII. Authorized Official

Name: ANGIE LANEA GROVE
Title or Position: PROGRAM MANAGER/CEO
Credential:
Phone: 817-962-9526