Healthcare Provider Details

I. General information

NPI: 1780225748
Provider Name (Legal Business Name): GRANVILLE OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 09/15/2022
Certification Date: 09/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 COVENTRY DR
OXFORD NC
27565-4005
US

IV. Provider business mailing address

200 COVENTRY DR
OXFORD NC
27565-4005
US

V. Phone/Fax

Practice location:
  • Phone: 919-742-4052
  • Fax:
Mailing address:
  • Phone: 919-742-4052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MS. CHARLES E TREFZGER JR.
Title or Position: MANAGER
Credential:
Phone: 828-270-0651