Provider Demographics
NPI:1164615951
Name:GRACE CHURCH COMMUNITY CENTER, INC
Entity Type:Organization
Organization Name:GRACE CHURCH COMMUNITY CENTER, INC
Other - Org Name:NEIGHBORS PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON-WINCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-949-3098
Mailing Address - Street 1:52 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10603-3710
Mailing Address - Country:US
Mailing Address - Phone:914-949-3098
Mailing Address - Fax:914-761-2105
Practice Address - Street 1:148 HAMILTON AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-1702
Practice Address - Country:US
Practice Address - Phone:914-949-3112
Practice Address - Fax:914-949-5952
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE CHURCH COMMUNITY CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-24
Last Update Date:2007-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6012L001251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01794729Medicaid