Provider Demographics
NPI:1659445294
Name:GRACEWORKS ENHANCED LIVING
Entity Type:Organization
Organization Name:GRACEWORKS ENHANCED LIVING
Other - Org Name:LOCKLAND HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE & FACILITIE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-436-6885
Mailing Address - Street 1:11370 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4202
Mailing Address - Country:US
Mailing Address - Phone:513-612-6500
Mailing Address - Fax:513-612-6545
Practice Address - Street 1:450 WYOMING AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45215-4451
Practice Address - Country:US
Practice Address - Phone:513-821-9066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACEWORKS ENHANCED LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-17
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3112625320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH=========OtherTAX ID