MEDICARE: GRACEVILLA,INC

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	314000000X	Skilled Nursing Facility	940000173	CA

General Provider Information

NPI Number	:	1396161261
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACEVILLA,INC

Provider Business Mailing Address
First Line	:	540 W. MOTE VISTA AVE
Second Line	:
City	:	VACAVILLE
State	:	CA
Zip	:	95688-3620
Country	:	US
Telephone Number	:	707-449-3400
Fax Number	:	707-450-0954

Provider Business Practice Location Address
First Line	:	1201 WALNUT AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90813-3822
Country	:	US
Telephone Number	:	562-591-7621
Fax Number	:	562-591-3292

Authorized Official
Title or Position	:	COO
Name	:	TRILOCHAN SINGH
Credential	:
Telephone Number	:	510-468-1909

Provider Enumeration Date	:	03/14/2014
Last Update Date	:	03/14/2014

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Directions to “GRACEVILLA,INC ” Practice Location

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