MEDICARE: GRACE'S PLACE ALF 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	311500000X	Alzheimer Center (Dementia Center)
2	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1629846209
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE'S PLACE ALF LLC

Provider Business Mailing Address
First Line	:	1121 ENSENADA DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-8307
Country	:	US
Telephone Number	:	407-924-8103
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 ENSENADA DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32825-8307
Country	:	US
Telephone Number	:	407-924-8103
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEBORAH MILLER
Credential	:
Telephone Number	:	407-924-8103

Provider Enumeration Date	:	12/13/2023
Last Update Date	:	12/13/2023

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