Provider Demographics
NPI:1598809634
Name:ST. GRACE HOSPICE, INC.
Entity Type:Organization
Organization Name:ST. GRACE HOSPICE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:JANET
Authorized Official - Last Name:HAYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-723-1175
Mailing Address - Street 1:904 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4576
Mailing Address - Country:US
Mailing Address - Phone:909-723-1175
Mailing Address - Fax:909-723-1174
Practice Address - Street 1:904 W 9TH ST
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4576
Practice Address - Country:US
Practice Address - Phone:909-723-1175
Practice Address - Fax:909-723-1174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000548251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1598809634Medicaid
CA551545Medicare PIN