Provider Demographics
NPI:1023556776
Name:GRACE STREET SERVICES, LLC
Entity Type:Organization
Organization Name:GRACE STREET SERVICES, LLC
Other - Org Name:GRACE STREET SOUTH
Other - Org Type:Other Name
Authorized Official - Title/Position:BILLING CONTACT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-245-1800
Mailing Address - Street 1:550 LISBON ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-6580
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:69 EAGLE DRIVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073
Practice Address - Country:US
Practice Address - Phone:207-245-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility