Provider Demographics
NPI:1265020697
Name:GRACEWORKS ENHANCED LIVING
Entity Type:Organization
Organization Name:GRACEWORKS ENHANCED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE & FACILITIE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-436-6885
Mailing Address - Street 1:11370 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:612 FREDERICKSBURG DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2649
Practice Address - Country:US
Practice Address - Phone:937-331-8141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACEWORKS ENHANCED LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-12-31
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities