Basic Information
| Provider Information | |||||||||
| NPI: | 1356332837 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACE PRESBYTERIAN MINISTRIES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRACE PRESBYTERIAN VILLAGE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12467 MERIT DR | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752512344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2144131523 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 E ANN ARBOR AVE | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752166718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143761701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | RICHARDSON | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | EARL | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR HEALTHCARE SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 2142268068 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 004284 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 000428401 | 05 | TX | MEDICAID |