Provider Demographics
NPI:1063257699
Name:GRACEFUL LIVING RESIDENTIAL CARE, LLC
Entity type:Organization
Organization Name:GRACEFUL LIVING RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ETHIOPIA
Authorized Official - Middle Name:WORKU
Authorized Official - Last Name:GEZAHAGN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-424-4507
Mailing Address - Street 1:5544 CRAFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:TN
Mailing Address - Zip Code:37013-4882
Mailing Address - Country:US
Mailing Address - Phone:615-424-4507
Mailing Address - Fax:
Practice Address - Street 1:5544 CRAFTWOOD DR
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:TN
Practice Address - Zip Code:37013-4882
Practice Address - Country:US
Practice Address - Phone:615-424-4507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-26
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care