Provider Demographics
NPI:1063445914
Name:GRACELAND NURSING CENTER, LLC
Entity Type:Organization
Organization Name:GRACELAND NURSING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLA
Authorized Official - Middle Name:PAGE
Authorized Official - Last Name:SCANNICCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-766-3977
Mailing Address - Street 1:1250 FARROW RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38116-7116
Mailing Address - Country:US
Mailing Address - Phone:901-332-7290
Mailing Address - Fax:901-332-7380
Practice Address - Street 1:1250 FARROW RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38116-7116
Practice Address - Country:US
Practice Address - Phone:901-332-7290
Practice Address - Fax:901-332-7380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN326314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440566Medicaid
TN0445331Medicaid
TN0445331Medicaid