=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003559998
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANDMAS COMFORT & CARING HAND, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2022
-----------------------------------------------------
Last Update Date | 04/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5944 LOCKAMY LN
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-470-6190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5944 LOCKAMY LN
-----------------------------------------------------
City | NORFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23502-2709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-470-6190
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. QUTRELL PAYTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 757-470-6190
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320600000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------