Provider Demographics
NPI:1033864525
Name:AGING GRACE SENIOR LIVING FACILITY LLC
Entity Type:Organization
Organization Name:AGING GRACE SENIOR LIVING FACILITY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-508-8421
Mailing Address - Street 1:1519 ROSE QUARTZ LN
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-3434
Mailing Address - Country:US
Mailing Address - Phone:760-508-8421
Mailing Address - Fax:
Practice Address - Street 1:11539 HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1927
Practice Address - Country:US
Practice Address - Phone:760-508-8421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility