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General NPI Number Information
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NPI Number | 1194033894
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Entity Type | Organization
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Legal Business Name | GRACEY MANOR LLC
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Dates
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Enumeration Date | 09/16/2010
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Last Update Date | 09/16/2010
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Provider Practice Location Address
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Address Line | 3400 YOUTH MONROE RD
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City | LOGANVILLE
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State | GA
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Zip | 30052-4327
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Country | US
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Telephone | 770-466-1535
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Fax |
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Provider Business Mailing Address
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Address Line | 3400 YOUTH MONROE RD
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City | LOGANVILLE
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State | GA
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Zip | 30052-4327
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ON SITE MANAGER
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Name | MRS. SHAUNDELL BLEGE
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Credential |
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Telephone | 404-889-7145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 147010191
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License Number State | GA
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