Provider Demographics
NPI:1215459193
Name:GRACE HOMESTEAD LLC
Entity type:Organization
Organization Name:GRACE HOMESTEAD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-235-7900
Mailing Address - Street 1:6604 HERBERT RD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7239
Mailing Address - Country:US
Mailing Address - Phone:469-235-7900
Mailing Address - Fax:
Practice Address - Street 1:6604 HERBERT RD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-7239
Practice Address - Country:US
Practice Address - Phone:469-235-7900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-12
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 251S00000X, 320600000X, 320900000X
TX102479310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251S00000XAgenciesCommunity/Behavioral Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities