=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790588952
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AGING GRACEFULLY ASSISTED LIVING RESIDENCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2025
-----------------------------------------------------
Last Update Date | 03/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 PINEDALE AVE
-----------------------------------------------------
City | ARCOLA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77583-2735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-232-3081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 PINEDALE AVE
-----------------------------------------------------
City | ARCOLA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77583-2735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-232-3081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | EZIMENA T DAFETTA
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 832-232-3081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------