Provider Demographics
NPI:1750168977
Name:GRACE SENIOR LIVING, LLC
Entity type:Organization
Organization Name:GRACE SENIOR LIVING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LEONA
Authorized Official - Middle Name:C
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MPH
Authorized Official - Phone:772-812-8749
Mailing Address - Street 1:2317 SW WEBSTER LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5752
Mailing Address - Country:US
Mailing Address - Phone:772-812-8749
Mailing Address - Fax:772-255-2780
Practice Address - Street 1:2317 SW WEBSTER LN
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-5752
Practice Address - Country:US
Practice Address - Phone:772-812-8749
Practice Address - Fax:772-255-2780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRACE SENIOR LIVING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-11
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities