Provider Demographics
NPI:1043733231
Name:GRACELAND HOMES, LLC
Entity type:Organization
Organization Name:GRACELAND HOMES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:LANEA
Authorized Official - Last Name:GROVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-962-9526
Mailing Address - Street 1:603 AMBARELLA ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-4505
Mailing Address - Country:US
Mailing Address - Phone:817-962-9529
Mailing Address - Fax:
Practice Address - Street 1:603 AMBARELLA STREET
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-7600
Practice Address - Country:US
Practice Address - Phone:817-962-9529
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-20
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities