MEDICARE: AUSTIN GRACE HOME 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1932994001
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AUSTIN GRACE HOME LLC

Provider Business Mailing Address
First Line	:	12004 COPPERSTONE AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-4518
Country	:	US
Telephone Number	:	512-956-3938
Fax Number	:

Provider Business Practice Location Address
First Line	:	12004 COPPERSTONE AVE
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-4518
Country	:	US
Telephone Number	:	512-956-3938
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MR. SERGE MANZI
Credential	:
Telephone Number	:	512-956-3938

Provider Enumeration Date	:	04/10/2025
Last Update Date	:	04/10/2025

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