MEDICARE: GRACE WOODS NILES OPCO, 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

General Provider Information

NPI Number	:	1205373735
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE WOODS NILES OPCO, LLC

Provider Business Mailing Address
First Line	:	7261 ENGLE RD
Second Line	:	STE 200
City	:	MIDDLEBURG HEIGHTS
State	:	OH
Zip	:	44130-8467
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	730 YOUNGSTOWN WARREN RD
Second Line	:
City	:	NILES
State	:	OH
Zip	:	44446-3578
Country	:	US
Telephone Number	:	330-652-4177
Fax Number	:

Authorized Official
Title or Position	:	GENERAL COUNSEL
Name	:	BENJAMIN PARSONS
Credential	:
Telephone Number	:	216-772-1105

Provider Enumeration Date	:	01/23/2017
Last Update Date	:	01/23/2017

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