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General NPI Number Information
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NPI Number | 1467821512
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Entity Type | Organization
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Legal Business Name | GRACE HOME LIVING FACILITY LLC
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Dates
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Enumeration Date | 09/18/2015
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Last Update Date | 09/18/2015
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Provider Practice Location Address
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Address Line | 2821 HUNT ST
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City | JACKSONVILLE
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State | FL
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Zip | 32254-4003
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Country | US
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Telephone | 904-379-6710
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Fax |
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Provider Business Mailing Address
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Address Line | 2821 HUNT ST
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City | JACKSONVILLE
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State | FL
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Zip | 32254-4003
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Country | US
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Telephone | 904-379-6710
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. COLLETTE KATRELL HOLMES
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Credential |
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Telephone | 904-673-7212
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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 | AL12677
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License Number State | FL
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