Provider Demographics
NPI:1790592012
Name:GRACEFUL RESIDENTIAL LLC
Entity type:Organization
Organization Name:GRACEFUL RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:OGACHI
Authorized Official - Last Name:AREBA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-205-1423
Mailing Address - Street 1:49 ARLINGTON
Mailing Address - Street 2:ARLINGTON COURT
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-3552
Mailing Address - Country:US
Mailing Address - Phone:612-205-1423
Mailing Address - Fax:
Practice Address - Street 1:49 ARLINGTON
Practice Address - Street 2:ARLINGTON COURT
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-3552
Practice Address - Country:US
Practice Address - Phone:612-205-1423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities