Healthcare Provider Details

I. General information

NPI: 1194931857
Provider Name (Legal Business Name): GRAND VIEW CARE LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 ROUND HILL DR
GRAND JUNCTION CO
81506-1438
US

IV. Provider business mailing address

647 ROUND HILL DR
GRAND JUNCTION CO
81506-1438
US

V. Phone/Fax

Practice location:
  • Phone: 970-241-8896
  • Fax: 970-241-8799
Mailing address:
  • Phone: 970-241-8896
  • Fax: 970-241-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateCO

VIII. Authorized Official

Name: KORENE M. EWING
Title or Position: ADMINISTRATOR
Credential:
Phone: 970-241-8896