Healthcare Provider Details

I. General information

NPI: 1740942622
Provider Name (Legal Business Name): GRANGEVILLE OF CASCADIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2021
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 E NORTH 2ND ST
GRANGEVILLE ID
83530-2258
US

IV. Provider business mailing address

2205 E RIVERSIDE DR STE 100
EAGLE ID
83616-7621
US

V. Phone/Fax

Practice location:
  • Phone: 208-983-1131
  • Fax:
Mailing address:
  • Phone: 208-401-9600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: OWEN C HAMMOND
Title or Position: PRESIDENT
Credential:
Phone: 208-401-9600