Provider Demographics
NPI:1417308966
Name:GOOD GRACE PROVIDER SERVICE
Entity Type:Organization
Organization Name:GOOD GRACE PROVIDER SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:CMG
Authorized Official - Phone:832-890-5451
Mailing Address - Street 1:15155 RICHMOND AVE APT 833
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082
Mailing Address - Country:US
Mailing Address - Phone:832-890-5451
Mailing Address - Fax:832-210-2210
Practice Address - Street 1:15155 RICHMOND AVE APT 833
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-1637
Practice Address - Country:US
Practice Address - Phone:832-890-5451
Practice Address - Fax:832-210-2210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization