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General NPI Number Information
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NPI Number | 1306415849
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Entity Type | Organization
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Legal Business Name | GRAND B1
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Dates
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Enumeration Date | 06/19/2021
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Last Update Date | 06/21/2021
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Provider Practice Location Address
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Address Line | 6523 N SHERIDAN RD
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City | EDMORE
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State | MI
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Zip | 48829-9726
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Country | US
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Telephone | 231-354-6564
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Fax | 231-354-6521
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Provider Business Mailing Address
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Address Line | 11400 CORAL RD
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City | CORAL
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State | MI
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Zip | 49322-9649
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Country | US
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Telephone | 231-354-6564
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | LINDA V POWELL
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Credential | AFC
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Telephone | 231-354-6564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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