MEDICARE: GRACE OF MONACO 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	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1871065508
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRACE OF MONACO LLC

Provider Business Mailing Address
First Line	:	7952 MONACO BAY CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2512
Country	:	US
Telephone Number	:	702-984-6059
Fax Number	:	702-984-6059

Provider Business Practice Location Address
First Line	:	7952 MONACO BAY CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-2512
Country	:	US
Telephone Number	:	702-984-6059
Fax Number	:	702-984-6059

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. RAMONCITO E GARCIA
Credential	:
Telephone Number	:	702-236-6642

Provider Enumeration Date	:	12/19/2018
Last Update Date	:	12/19/2018

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