MEDICARE: GRACELAND HOMES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1043733231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACELAND HOMES, LLC

Provider Business Mailing Address
First Line	:	603 AMBARELLA ST
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-4505
Country	:	US
Telephone Number	:	817-962-9529
Fax Number	:

Provider Business Practice Location Address
First Line	:	603 AMBARELLA STREET
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76002-7600
Country	:	US
Telephone Number	:	817-962-9529
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER/CEO
Name	:	ANGIE LANEA GROVE
Credential	:
Telephone Number	:	817-962-9526

Provider Enumeration Date	:	07/20/2017
Last Update Date	:	08/03/2017

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