MEDICARE: GRACE WOODS SENIOR LIVING, 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	310400000X	Assisted Living Facility	2425R	OH

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

General Provider Information

NPI Number	:	1801016639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE WOODS SENIOR LIVING, LLC

Provider Business Mailing Address
First Line	:	730 YOUNGSTOWN WARREN RD
Second Line	:
City	:	NILES
State	:	OH
Zip	:	44446-3578
Country	:	US
Telephone Number	:	330-652-4177
Fax Number	:	330-652-2295

Provider Business Practice Location Address
First Line	:	730 YOUNGSTOWN WARREN RD
Second Line	:
City	:	NILES
State	:	OH
Zip	:	44446-3578
Country	:	US
Telephone Number	:	330-652-4177
Fax Number	:	330-652-2295

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. EDWARD J FABIAN
Credential	:	N.H.A.
Telephone Number	:	330-652-4177

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	08/22/2020

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