1083145114 NPI number — CPLACE JASPER SNF LLC

Table of content: (NPI 1083145114)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083145114 NPI number — CPLACE JASPER SNF LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CPLACE JASPER SNF LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GRANDVIEW HEATH CARE CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083145114
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/21/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24641 US HIGHWAY 19 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33763-5007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 GENNETT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30143-1143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-692-5123
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/21/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MARCOS
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
917-209-1431

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1-112-1479 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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