Provider Demographics
NPI:1760734149
Name:RAE ANN MOXLEY
Entity Type:Organization
Organization Name:RAE ANN MOXLEY
Other - Org Name:GRACE ASSISTED LIVING
Other - Org Type:Other Name
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RAE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MOXLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-293-9980
Mailing Address - Street 1:459 CONIFER RD
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-2966
Mailing Address - Country:US
Mailing Address - Phone:406-295-9980
Mailing Address - Fax:
Practice Address - Street 1:459 CONIFER RD
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2966
Practice Address - Country:US
Practice Address - Phone:406-295-9980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT0044364-001320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0044364-001OtherMT ST DEPT. OF PUBLIC HEALTH AND HUMAN SERVICES LICENSE FOR ADULT FOSTER HOME