Provider Demographics
NPI:1063271054
Name:GRACE LOVE RECOVERY
Entity type:Organization
Organization Name:GRACE LOVE RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANAH
Authorized Official - Middle Name:
Authorized Official - Last Name:NANKUNDA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-439-1631
Mailing Address - Street 1:970 E CORRALL ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-2757
Mailing Address - Country:US
Mailing Address - Phone:702-439-1631
Mailing Address - Fax:
Practice Address - Street 1:970 E CORRALL ST
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-2757
Practice Address - Country:US
Practice Address - Phone:702-439-1631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-13
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness