=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245068717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GIVING GRACE GROUP HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2024
-----------------------------------------------------
Last Update Date | 07/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 E ROBERT ST
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-6627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-352-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 E ROBERT ST
-----------------------------------------------------
City | FT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-6627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-352-0102
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELISHA ANN CHAMBERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-352-0102
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------