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General NPI Number Information
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NPI Number | 1477098531
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Entity Type | Organization
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Legal Business Name | GRACE THEIOS, LLC
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Dates
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Enumeration Date | 12/28/2016
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Last Update Date | 06/26/2025
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Provider Practice Location Address
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Address Line | 6031 COUNTY ROAD 105
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City | CARTHAGE
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State | MO
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Zip | 64836
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Country | US
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Telephone | 417-317-4434
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Fax |
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Provider Business Mailing Address
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Address Line | 6031 COUNTY ROAD 105
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City | CARTHAGE
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State | MO
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Zip | 64836
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Country | US
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Telephone | 417-317-4434
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | IGOR GONZALEZ
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Credential |
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Telephone | 417-392-1297
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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License Number |
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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