Provider Demographics
NPI:1194177097
Name:GRACE ASSISTED LIVING, LLC
Entity type:Organization
Organization Name:GRACE ASSISTED LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:H
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:941-766-7178
Mailing Address - Street 1:16658 SAN EDMUNDO RD
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33955-4040
Mailing Address - Country:US
Mailing Address - Phone:646-220-6106
Mailing Address - Fax:941-621-4975
Practice Address - Street 1:22091 PEACHLAND BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33954-3352
Practice Address - Country:US
Practice Address - Phone:941-766-7178
Practice Address - Fax:941-621-4975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12849310400000X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness