Provider Demographics
NPI:1073106373
Name:HOUSE OF GRACES LLC
Entity Type:Organization
Organization Name:HOUSE OF GRACES LLC
Other - Org Name:HOUSE OF GRACES LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-379-3850
Mailing Address - Street 1:4260 N 19TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-5108
Mailing Address - Country:US
Mailing Address - Phone:775-379-3850
Mailing Address - Fax:
Practice Address - Street 1:4260 N 19TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-5108
Practice Address - Country:US
Practice Address - Phone:775-379-3850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOUSE OF GRACES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-17
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health