MEDICARE: GRACELAND RESIDENTIAL 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1801561873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACELAND RESIDENTIAL LLC

Provider Business Mailing Address
First Line	:	24220 CHURCH ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-1510
Country	:	US
Telephone Number	:	520-336-3026
Fax Number	:

Provider Business Practice Location Address
First Line	:	24220 CHURCH ST
Second Line	:
City	:	OAK PARK
State	:	MI
Zip	:	48237-1510
Country	:	US
Telephone Number	:	520-336-3026
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SIDNEY ATEMNKENG
Credential	:
Telephone Number	:	520-336-3026

Provider Enumeration Date	:	08/12/2021
Last Update Date	:	08/12/2021

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