Basic Information
| Provider Information | |||||||||
| NPI: | 1669773735 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GRACE FULL LIVING FOR SENIORS INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | THE GREEN BENCH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 747 BON AIR ST | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636881196 | ||||||||
| FaxNumber: | 8636877707 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 49TH ST N | ||||||||
| Address2: | |||||||||
| City: | ST PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337107320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273281414 | ||||||||
| FaxNumber: | 7273288433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2010 | ||||||||
| LastUpdateDate: | 11/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | GASMENA | ||||||||
| AuthorizedOfficialFirstName: | PIER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8635957353 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.