MEDICARE: GRACE HOME ASSISTED LIVING 1

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	261QM0850X	Adult Mental Health Clinic/Center	AL6571H	AZ
2	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	AL6571-H	AZ
3	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	AL7454H	AZ
4	3747A0650X	Attendant Care Provider	AL7454-H	AZ
5	320700000X	Physical Disabilities Residential Treatment Facility	AL6571H	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	0301305850	OTHER	AZ	AARP
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	00416712603	OTHER	AZ	TRICARE PRIME INSURANCE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760916407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE HOME ASSISTED LIVING 1

Provider Business Mailing Address
First Line	:	2261 S QUAIL HOLLOW DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85710-7982
Country	:	US
Telephone Number	:	520-312-0225
Fax Number	:	520-207-2223

Provider Business Practice Location Address
First Line	:	2301 S QUAIL HOLLOW DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85710-7986
Country	:	US
Telephone Number	:	520-312-0225
Fax Number	:	520-207-2223

Authorized Official
Title or Position	:	OWNER
Name	:	NORMA BRAGA
Credential	:
Telephone Number	:	520-312-0225

Provider Enumeration Date	:	04/19/2017
Last Update Date	:	04/19/2017

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Directions to “GRACE HOME ASSISTED LIVING 1 ” Practice Location

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