Provider Demographics
NPI:1346996287
Name:GRACIOUS BY YOUR SIDE LLC
Entity Type:Organization
Organization Name:GRACIOUS BY YOUR SIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DIETRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-308-7991
Mailing Address - Street 1:PO BOX 74083
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-0083
Mailing Address - Country:US
Mailing Address - Phone:810-308-7991
Mailing Address - Fax:
Practice Address - Street 1:35675 GARNER ST
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-4129
Practice Address - Country:US
Practice Address - Phone:810-308-7991
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-01
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health