Basic Information
| Provider Information | |||||||||
| NPI: | 1720284482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACE ASSISTED LIVING OF BREMEN, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 78 CENTENNIAL LOOP | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974017900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417473373 | ||||||||
| FaxNumber: | 5417470673 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 GORDON ST | ||||||||
| Address2: | |||||||||
| City: | BREMEN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301101525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705376800 | ||||||||
| FaxNumber: | 7705371067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 05/13/2008 | ||||||||
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| AuthorizedOfficialLastName: | HOLTZ | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 5417473373 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305S00000X | Y | Managed Care Organizations | Point of Service |
No ID Information.