Provider Demographics
NPI:1376190025
Name:C&G'S GRACE PLACE LLC
Entity Type:Organization
Organization Name:C&G'S GRACE PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LATESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GASKIKNS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-468-5303
Mailing Address - Street 1:6763 KRENSON OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2157
Mailing Address - Country:US
Mailing Address - Phone:813-468-5303
Mailing Address - Fax:863-578-3659
Practice Address - Street 1:6763 KRENSON OAKS CIR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-2157
Practice Address - Country:US
Practice Address - Phone:813-468-5303
Practice Address - Fax:863-578-3659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-19
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities