Provider Demographics
NPI:1861755480
Name:GRACE COMMUNITY CENTER DAY REHABILITATION PROGRAM
Entity type:Organization
Organization Name:GRACE COMMUNITY CENTER DAY REHABILITATION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:408-794-7592
Mailing Address - Street 1:146 S 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3641
Mailing Address - Country:US
Mailing Address - Phone:408-794-7580
Mailing Address - Fax:
Practice Address - Street 1:146 S 10TH ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-3641
Practice Address - Country:US
Practice Address - Phone:408-794-7580
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14707251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health