Provider Demographics
NPI:1174379507
Name:AGING GRACEFULLY LLC MEMORY CARE
Entity type:Organization
Organization Name:AGING GRACEFULLY LLC MEMORY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CORNELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:OBRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:971-222-8710
Mailing Address - Street 1:24502 DREW GAP
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78255-2284
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6202 HOLLYHOCK RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-2518
Practice Address - Country:US
Practice Address - Phone:210-799-3181
Practice Address - Fax:210-579-8022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-26
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility