Provider Demographics
NPI:1427306844
Name:GRACE VILLA FACILITY LLC
Entity type:Organization
Organization Name:GRACE VILLA FACILITY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:HAFEEZ
Authorized Official - Middle Name:RAHAMAN
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-895-8418
Mailing Address - Street 1:321 E HARVARD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5526
Mailing Address - Country:US
Mailing Address - Phone:407-895-8418
Mailing Address - Fax:407-895-8229
Practice Address - Street 1:321 E HARVARD STREET
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804
Practice Address - Country:US
Practice Address - Phone:407-895-8418
Practice Address - Fax:407-895-8229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL8445310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675965300Medicaid