Provider Demographics
NPI:1285156356
Name:HACIENDAS AT GRACE VILLAGE, LLC
Entity type:Organization
Organization Name:HACIENDAS AT GRACE VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:COPPEDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-524-1020
Mailing Address - Street 1:2802 CORTE DIOS
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8140
Mailing Address - Country:US
Mailing Address - Phone:575-524-1020
Mailing Address - Fax:
Practice Address - Street 1:2802 CORTE DIOS
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8140
Practice Address - Country:US
Practice Address - Phone:575-524-1020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility