MEDICARE: CONSCIOUS GRACE ADULT SERVICE, 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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1467046540
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONSCIOUS GRACE ADULT SERVICE, LLC

Provider Business Mailing Address
First Line	:	4830 MONTCLAIR HILL LN
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2036
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4830 MONTCLAIR HILL LN
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-2036
Country	:	US
Telephone Number	:	832-207-3147
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JAMAAL PASKEL
Credential	:
Telephone Number	:	832-207-3147

Provider Enumeration Date	:	03/01/2021
Last Update Date	:	03/04/2021

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