1790069656 NPI number — GRAYSON ASSISTED LIVING FACILITY

Table of content: (NPI 1790069656)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790069656 NPI number — GRAYSON ASSISTED LIVING FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAYSON ASSISTED LIVING FACILITY
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:
Provider Other Organization Name Type Code:
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:
1790069656
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 OLD TRAIL
Provider Second Line Business Mailing Address:
3455 ST RT 75
Provider Business Mailing Address City Name:
HUNTINGTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-972-0815
Provider Business Mailing Address Fax Number:
304-972-0814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 OLD TRL
Provider Second Line Business Practice Location Address:
3455 ST RT 75
Provider Business Practice Location Address City Name:
HUNTINGTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25704-9281
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-972-0815
Provider Business Practice Location Address Fax Number:
304-972-0814
Provider Enumeration Date:
10/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
GRAYSON
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
DWAYNE
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
304-417-4969

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  507554 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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