Provider Demographics
NPI:1780724484
Name:GRACE DEVELOPMENT CLAN INC.
Entity type:Organization
Organization Name:GRACE DEVELOPMENT CLAN INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-480-8369
Mailing Address - Street 1:3502 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-3416
Mailing Address - Country:US
Mailing Address - Phone:336-480-8369
Mailing Address - Fax:336-721-1176
Practice Address - Street 1:3502 CHERRY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-3416
Practice Address - Country:US
Practice Address - Phone:336-480-8369
Practice Address - Fax:336-721-1176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL034210320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities