Provider Demographics
NPI:1164964383
Name:ST, GRACE HOSPICE, INC.
Entity Type:Organization
Organization Name:ST, GRACE HOSPICE, INC.
Other - Org Name:ST. GRACE MANOR 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:JANET
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-545-4462
Mailing Address - Street 1:4440 FAUNA ST
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-3523
Mailing Address - Country:US
Mailing Address - Phone:951-545-4462
Mailing Address - Fax:
Practice Address - Street 1:4440 FAUNA ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763-3523
Practice Address - Country:US
Practice Address - Phone:951-545-4462
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility