Provider Demographics
NPI:1811617889
Name:GRACELAND BEHAVIORAL HOME LLC
Entity type:Organization
Organization Name:GRACELAND BEHAVIORAL HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KOFI
Authorized Official - Middle Name:OWUSU
Authorized Official - Last Name:KUSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-752-7158
Mailing Address - Street 1:35696 W SANTA MONICA AVE
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-2620
Mailing Address - Country:US
Mailing Address - Phone:602-752-7158
Mailing Address - Fax:
Practice Address - Street 1:35696 W SANTA MONICA AVE
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-2620
Practice Address - Country:US
Practice Address - Phone:602-752-7158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances