Provider Demographics
NPI:1033201611
Name:GRACEWORKS LUTHERAN SERVICES
Entity Type:Organization
Organization Name:GRACEWORKS LUTHERAN SERVICES
Other - Org Name:BETHANY VILLAGE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:REICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:937-436-6865
Mailing Address - Street 1:6451 FAR HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-2725
Mailing Address - Country:US
Mailing Address - Phone:937-433-2110
Mailing Address - Fax:
Practice Address - Street 1:6451 FAR HILLS AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2725
Practice Address - Country:US
Practice Address - Phone:937-433-2110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-29
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0632N314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0684255Medicaid
OH365493Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER