Provider Demographics
NPI:1821422916
Name:GRACEWORKS ENHANCED LIVING
Entity Type:Organization
Organization Name:GRACEWORKS ENHANCED LIVING
Other - Org Name:KEMPER MEADOW HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT, FINANCE & FACILITIE
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:W
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:937-436-6885
Mailing Address - Street 1:11370 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4202
Mailing Address - Country:US
Mailing Address - Phone:513-612-6500
Mailing Address - Fax:513-612-6546
Practice Address - Street 1:1045 KEMPER MEADOW DRIVE
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:OH
Practice Address - Zip Code:45240
Practice Address - Country:US
Practice Address - Phone:513-648-0830
Practice Address - Fax:513-612-6545
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACEWORKS ENHANCED LIVING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-26
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0090195Medicaid
OH36-G673OtherCMS CERTIFICATION NUMBER (CCN)