Provider Demographics
NPI:1710323753
Name:SPECIAL GRACES LLC
Entity Type:Organization
Organization Name:SPECIAL GRACES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:409-658-3411
Mailing Address - Street 1:PO BOX 841895
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-0026
Mailing Address - Country:US
Mailing Address - Phone:409-658-3411
Mailing Address - Fax:
Practice Address - Street 1:74 TERRA BELLA DR
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-3340
Practice Address - Country:US
Practice Address - Phone:409-658-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health