Provider Demographics
NPI:1760710206
Name:GRACE COTTAGE
Entity Type:Organization
Organization Name:GRACE COTTAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-394-7696
Mailing Address - Street 1:1616 2ND ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-1247
Mailing Address - Country:US
Mailing Address - Phone:209-394-9676
Mailing Address - Fax:209-394-7694
Practice Address - Street 1:1616 2ND ST
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-1247
Practice Address - Country:US
Practice Address - Phone:209-394-9676
Practice Address - Fax:209-394-7694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550001115315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities