Provider Demographics
NPI:1194159996
Name:GRACES PALACES
Entity type:Organization
Organization Name:GRACES PALACES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ETHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-626-6161
Mailing Address - Street 1:1198 SE PETUNIA AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5323
Mailing Address - Country:US
Mailing Address - Phone:772-353-5235
Mailing Address - Fax:772-398-4238
Practice Address - Street 1:1198 SE PETUNIA AVE
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5323
Practice Address - Country:US
Practice Address - Phone:772-353-5235
Practice Address - Fax:772-398-4238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-28
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12295310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility