Basic Information
| Provider Information | |||||||||
| NPI: | 1285005272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACE HS LLC | ||||||||
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| OtherOrganizationName: | GRACE HEALTHCARE SERVICES, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14C 53RD ST | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112322644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185670400 | ||||||||
| FaxNumber: | 7185670600 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 FIELDCREST AVE | ||||||||
| Address2: | SUITE 402 | ||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088373628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8664470246 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2015 | ||||||||
| LastUpdateDate: | 10/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | STERN | ||||||||
| AuthorizedOfficialFirstName: | SAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7185670400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 24015 | NJ | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 0108707 | 05 | NJ | MEDICAID |