Provider Demographics
NPI:1235750753
Name:HOUSE OF G.R.A.C.E.RESIDENTIAL SERVICES, LLC
Entity Type:Organization
Organization Name:HOUSE OF G.R.A.C.E.RESIDENTIAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD , LISW-S
Authorized Official - Phone:330-915-8347
Mailing Address - Street 1:116 CLEVELAND AVE NW
Mailing Address - Street 2:SUITE 555
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44702-1779
Mailing Address - Country:US
Mailing Address - Phone:330-915-8347
Mailing Address - Fax:330-915-6030
Practice Address - Street 1:116 CLEVELAND AVE NW STE 555
Practice Address - Street 2:SUITE 555
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44702-1779
Practice Address - Country:US
Practice Address - Phone:330-915-8347
Practice Address - Fax:330-915-6030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-06
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7610455OtherOHIO DEPARTMENT OF DEVELOPMENTAL DISABILITIES
OH0215619Medicaid