MEDICARE: GRACE MEADOWS ASSISTED LIVING 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	310400000X	Assisted Living Facility	AL9915H	AZ

General Provider Information

NPI Number	:	1073973673
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE MEADOWS ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	4902 W BEVERLY LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85306-2028
Country	:	US
Telephone Number	:	602-978-1568
Fax Number	:

Provider Business Practice Location Address
First Line	:	4902 W BEVERLY LN
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85306-2028
Country	:	US
Telephone Number	:	602-978-1568
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ MANAGER
Name	:	MR. MIKE J OLEARY
Credential	:
Telephone Number	:	602-978-1563

Provider Enumeration Date	:	02/25/2016
Last Update Date	:	02/25/2016

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