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General NPI Number Information
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NPI Number | 1194177097
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Entity Type | Organization
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Legal Business Name | GRACE ASSISTED LIVING, LLC
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Dates
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Enumeration Date | 07/05/2016
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Last Update Date | 07/05/2016
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Provider Practice Location Address
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Address Line | 22091 PEACHLAND BLVD
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City | PORT CHARLOTTE
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State | FL
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Zip | 33954-3352
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Country | US
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Telephone | 941-766-7178
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Fax | 941-621-4975
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Provider Business Mailing Address
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Address Line | 16658 SAN EDMUNDO RD
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City | PUNTA GORDA
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State | FL
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Zip | 33955-4040
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Country | US
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Telephone | 646-220-6106
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Fax | 941-621-4975
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Authorized Official
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Title or Position | OWNER/ADMINISTRATOR
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Name | MS. GRACE H COOPER
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Credential | RN
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Telephone | 941-766-7178
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | AL12849
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL12849
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License Number State | FL
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