Provider Demographics
NPI:1912399254
Name:GRACE RELIANT HEALTHCARE, LLC
Entity Type:Organization
Organization Name:GRACE RELIANT HEALTHCARE, LLC
Other - Org Name:GRACE RELIANT HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-204-9200
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-0332
Mailing Address - Country:US
Mailing Address - Phone:573-204-9200
Mailing Address - Fax:573-243-7743
Practice Address - Street 1:510 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MO
Practice Address - Zip Code:63755-1741
Practice Address - Country:US
Practice Address - Phone:573-204-9200
Practice Address - Fax:573-243-7133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO253Z00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities