Provider Demographics
NPI:1750700860
Name:GRACE MANOR SUITES
Entity type:Organization
Organization Name:GRACE MANOR SUITES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:SAVITRI
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-226-0358
Mailing Address - Street 1:PO BOX 2480
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33806-2480
Mailing Address - Country:US
Mailing Address - Phone:863-937-9114
Mailing Address - Fax:863-510-5952
Practice Address - Street 1:4620 N SOCRUM LOOP ROAD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33809
Practice Address - Country:US
Practice Address - Phone:863-577-0977
Practice Address - Fax:863-577-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-16
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11995310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112829400Medicaid