Provider Demographics
NPI:1497925242
Name:GRACE OF SERENITY LIVING
Entity Type:Organization
Organization Name:GRACE OF SERENITY LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MEADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-441-4690
Mailing Address - Street 1:2720 E THOMAS RD STE 200B
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-8242
Mailing Address - Country:US
Mailing Address - Phone:602-441-4690
Mailing Address - Fax:
Practice Address - Street 1:6620 S 26TH DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85041-5366
Practice Address - Country:US
Practice Address - Phone:602-441-4690
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH2942320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ911695OtherAHCCS