Provider Demographics
NPI:1831854470
Name:GRACE, COMMUNITY SUPPORTED LIVING SERVICES
Entity type:Organization
Organization Name:GRACE, COMMUNITY SUPPORTED LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:GWEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-963-4357
Mailing Address - Street 1:1815 REDFIELD ST
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54601-5862
Mailing Address - Country:US
Mailing Address - Phone:608-963-4357
Mailing Address - Fax:
Practice Address - Street 1:4421 MORMON COULEE RD STE C
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54601-8220
Practice Address - Country:US
Practice Address - Phone:608-963-4357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty