=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629824008
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE MAJESTIC SENIOR RESIDENCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2024
-----------------------------------------------------
Last Update Date | 04/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 N 47TH AVE
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-362-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 N 47TH AVE
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-4700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-362-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | DIANE C WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-553-4985
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------