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General NPI Number Information
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NPI Number | 1053424549
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Entity Type | Organization
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Legal Business Name | GRANT MANOR, LLC
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 09/30/2009
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Provider Practice Location Address
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Address Line | 201 KIMBERLY LN
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City | WILLIAMSTOWN
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State | KY
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Zip | 41097-9458
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Country | US
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Telephone | 859-824-7803
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Fax | 859-824-9604
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Provider Business Mailing Address
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Address Line | 101 SUN AVE NE COMPLIANCE DEPARTMENT
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-4373
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Country | US
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Telephone | 505-468-5604
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Fax | 505-468-4681
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Authorized Official
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Title or Position | PRESIDENT DIRECTOR
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Name | WILLIAM A MATHIES
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Credential |
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Telephone | 505-821-3355
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 100694
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License Number State | KY
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