Provider Demographics
NPI:1841965399
Name:ABS ISLAND OF GRACE LLC
Entity type:Organization
Organization Name:ABS ISLAND OF GRACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:OLUKEMI
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNSANYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-805-4891
Mailing Address - Street 1:16327 ALAMETOS DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-2805
Mailing Address - Country:US
Mailing Address - Phone:832-805-4891
Mailing Address - Fax:
Practice Address - Street 1:16327 ALAMETOS DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77083-2805
Practice Address - Country:US
Practice Address - Phone:832-805-4891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities