MEDICARE: HOUSE OF G.R.A.C.E.RESIDENTIAL SERVICES, 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	261QD1600X	Developmental Disabilities Clinic/Center
2	251E00000X	Home Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7610455	OTHER	OH	OHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1235750753
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOUSE OF G.R.A.C.E.RESIDENTIAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	116 CLEVELAND AVE NW
Second Line	:	SUITE 555
City	:	CANTON
State	:	OH
Zip	:	44702-1779
Country	:	US
Telephone Number	:	330-915-8347
Fax Number	:	330-915-6030

Provider Business Practice Location Address
First Line	:	116 CLEVELAND AVE NW STE 555
Second Line	:	SUITE 555
City	:	CANTON
State	:	OH
Zip	:	44702-1779
Country	:	US
Telephone Number	:	330-915-8347
Fax Number	:	330-915-6030

Authorized Official
Title or Position	:	CEO
Name	:	AUDRA MARTIN
Credential	:	PHD , LISW-S
Telephone Number	:	330-915-8347

Provider Enumeration Date	:	05/06/2020
Last Update Date	:	11/17/2021

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