Provider Demographics
NPI:1588080451
Name:GRACEVILLA,INC
Entity type:Organization
Organization Name:GRACEVILLA,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TRILOCHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-468-1909
Mailing Address - Street 1:540 W MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3620
Mailing Address - Country:US
Mailing Address - Phone:707-449-3400
Mailing Address - Fax:707-450-0954
Practice Address - Street 1:723 E 9TH ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-4611
Practice Address - Country:US
Practice Address - Phone:562-491-2797
Practice Address - Fax:562-491-0945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-14
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA940000032314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA055329Medicare Oscar/Certification