Provider Demographics
NPI:1407399751
Name:GRACE QUALITY GROUPHOME LLC
Entity Type:Organization
Organization Name:GRACE QUALITY GROUPHOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GROUP HOME MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELISSAINT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:682-301-2042
Mailing Address - Street 1:5900 EMBER GLEN DR
Mailing Address - Street 2:
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76137-5809
Mailing Address - Country:US
Mailing Address - Phone:682-301-2042
Mailing Address - Fax:
Practice Address - Street 1:5900 EMBER GLEN DR
Practice Address - Street 2:
Practice Address - City:HALTOM CITY
Practice Address - State:TX
Practice Address - Zip Code:76137-5809
Practice Address - Country:US
Practice Address - Phone:682-301-2042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities