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NPI Code Detail

MEDICARE: GRANT MANOR, LLC

MEDICARE: GRANT MANOR, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility100694KY

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1053424549
Entity Type Code : Organization
Provider Name (Legal Business Name) : GRANT MANOR, LLC
Provider Business Mailing Address
First Line : 101 SUN AVE NE
Second Line : COMPLIANCE DEPARTMENT
City : ALBUQUERQUE
State : NM
Zip : 87109-4373
Country : US
Telephone Number : 505-468-5604
Fax Number : 505-468-4681
Provider Business Practice Location Address
First Line : 201 KIMBERLY LN
Second Line :
City : WILLIAMSTOWN
State : KY
Zip : 41097-9458
Country : US
Telephone Number : 859-824-7803
Fax Number : 859-824-9604
Authorized Official
Title or Position : PRESIDENT DIRECTOR
Name : WILLIAM A MATHIES
Credential :
Telephone Number : 505-821-3355
Provider Enumeration Date : 08/17/2006
Last Update Date : 09/30/2009

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Directions to “GRANT MANOR, LLC ” Practice Location

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