MEDICARE: GRANT COMMUNITY RESIDENTIAL HOME

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
1	172V00000X	Community Health Worker		FL

General Provider Information

NPI Number	:	1457853798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANT COMMUNITY RESIDENTIAL HOME

Provider Business Mailing Address
First Line	:	2252 WRIGHT STREET (A)
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916
Country	:	US
Telephone Number	:	239-935-9247
Fax Number	:	239-466-0142

Provider Business Practice Location Address
First Line	:	2252 WRIGHT STREET (A)
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33916
Country	:	US
Telephone Number	:	239-935-9247
Fax Number	:	239-466-0142

Authorized Official
Title or Position	:	AHCA PROVIDER
Name	:	MR. JAHPHET Y GRANT
Credential	:
Telephone Number	:	239-935-9247

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	03/02/2018

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