=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740278282
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAND MEADOW HEALTHCARE CENTER, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2005
-----------------------------------------------------
Last Update Date | 10/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 210 GRAND AVE W
-----------------------------------------------------
City | GRAND MEADOW
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55936-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-754-5226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 210 GRAND AVE W PO BOX 365
-----------------------------------------------------
City | GRAND MEADOW
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55936-1105
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HOWIE GROFF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-888-2923
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 326959
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 0029853
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------