Provider Demographics
NPI:1760916407
Name:GRACE HOME ASSISTED LIVING 1
Entity Type:Organization
Organization Name:GRACE HOME ASSISTED LIVING 1
Other - Org Name:GRACE HOME ASSISTED LIVING 2
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NORMA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-312-0225
Mailing Address - Street 1:2261 S QUAIL HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-7982
Mailing Address - Country:US
Mailing Address - Phone:520-312-0225
Mailing Address - Fax:520-207-2223
Practice Address - Street 1:2301 S QUAIL HOLLOW DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-7986
Practice Address - Country:US
Practice Address - Phone:520-312-0225
Practice Address - Fax:520-207-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-19
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL6571H261QM0850X, 320700000X
AZAL6571-H320900000X
AZAL7454H320900000X
AZAL7454-H3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95188554F13239OtherMEDICAID
AZ0301305850OtherAARP
AZ85808889OtherMEDICAID AND MUTUAL OF OMAHA
AZ00416712603OtherTRICARE PRIME INSURANCE
783517401OtherMEDICAID AND AARP