=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851449136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANVILLE HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2007
-----------------------------------------------------
Last Update Date | 01/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 COVENTRY DR
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565-4005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-692-1315
-----------------------------------------------------
Fax | 919-692-1363
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 COVENTRY DRIVE
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27565
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-692-1315
-----------------------------------------------------
Fax | 919-692-1363
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. CHARLES GROSS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 919-692-1315
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | HAL- 039-009
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------