Provider Demographics
NPI:1114197969
Name:GRACE OF SERENITY LIVING, INC
Entity Type:Organization
Organization Name:GRACE OF SERENITY LIVING, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-441-4690
Mailing Address - Street 1:2720 E THOMAS RD
Mailing Address - Street 2:B-200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8299
Mailing Address - Country:US
Mailing Address - Phone:602-441-4690
Mailing Address - Fax:
Practice Address - Street 1:8340 N 86TH LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-2553
Practice Address - Country:US
Practice Address - Phone:602-441-4690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2333322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ816803OtherAHCCS