MEDICARE: GRACE HOUSE MINISTRIES, 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	019448	AL

General Provider Information

NPI Number	:	1548376072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE HOUSE MINISTRIES, INC.

Provider Business Mailing Address
First Line	:	PO BOX 547
Second Line	:	4923 FARRELL AVE
City	:	FAIRFIELD
State	:	AL
Zip	:	35064-0547
Country	:	US
Telephone Number	:	205-786-4663
Fax Number	:	205-780-0750

Provider Business Practice Location Address
First Line	:	4923 FARRELL AVE
Second Line	:
City	:	FAIRFIELD
State	:	AL
Zip	:	35064-2337
Country	:	US
Telephone Number	:	205-786-4663
Fax Number	:	205-780-0750

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. JENNIFER PARKER
Credential	:
Telephone Number	:	205-786-4663

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	08/22/2020

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