Provider Demographics
NPI:1801016639
Name:GRACE WOODS SENIOR LIVING, LLC
Entity Type:Organization
Organization Name:GRACE WOODS SENIOR LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FABIAN
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:330-652-4177
Mailing Address - Street 1:730 YOUNGSTOWN WARREN RD
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:OH
Mailing Address - Zip Code:44446-3578
Mailing Address - Country:US
Mailing Address - Phone:330-652-4177
Mailing Address - Fax:330-652-2295
Practice Address - Street 1:730 YOUNGSTOWN WARREN RD
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:OH
Practice Address - Zip Code:44446-3578
Practice Address - Country:US
Practice Address - Phone:330-652-4177
Practice Address - Fax:330-652-2295
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2425R310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2706521Medicaid