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NPI Code Detail

MEDICARE: GRANDFATHER HOME COMMUNITY SERVICES FOR CHILDREN

MEDICARE: GRANDFATHER HOME COMMUNITY SERVICES FOR CHILDREN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1320800000XMental Illness Community Based Residential Treatment FacilityMHL-034-015NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1588721591
Entity Type Code : Organization
Provider Name (Legal Business Name) : GRANDFATHER HOME COMMUNITY SERVICES FOR CHILDREN
Provider Business Mailing Address
First Line : PO BOX 98
Second Line :
City : BANNER ELK
State : NC
Zip : 28604-0098
Country : US
Telephone Number : 828-898-5465
Fax Number : 828-898-8513
Provider Business Practice Location Address
First Line : 5560 STURMER PARK CIR
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27105-1372
Country : US
Telephone Number : 828-898-5465
Fax Number : 828-898-8513
Authorized Official
Title or Position : CEO
Name : MR. JIM SWINKOLA
Credential : MBA, MSW
Telephone Number : 828-898-5465
Provider Enumeration Date : 01/02/2007
Last Update Date : 02/22/2008

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Directions to “GRANDFATHER HOME COMMUNITY SERVICES FOR CHILDREN ” Practice Location

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