Provider Demographics
NPI:1245532985
Name:GRACE COMMUNITY LIVING
Entity type:Organization
Organization Name:GRACE COMMUNITY LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:TIFFANI
Authorized Official - Middle Name:ALYCE
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:478-747-9329
Mailing Address - Street 1:1495 WESTMINISTER DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-4844
Mailing Address - Country:US
Mailing Address - Phone:478-254-4129
Mailing Address - Fax:347-710-9329
Practice Address - Street 1:2402 ANTHONY TER
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3120
Practice Address - Country:US
Practice Address - Phone:478-788-9706
Practice Address - Fax:347-710-9329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011-01-114-1311Z00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility