Provider Demographics
NPI: | 1124209507 |
---|---|
Name: | GRAND CHALET |
Entity Type: | Organization |
Organization Name: | GRAND CHALET |
Other - Org Name: | ABILITIES TO ACHIEVE, INC. |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | BOOKKEEPER |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | CLAIRE |
Authorized Official - Middle Name: | LIZETH |
Authorized Official - Last Name: | HOLCOMB |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 707-643-4843 |
Mailing Address - Street 1: | 328 KIMBERLY DR |
Mailing Address - Street 2: | |
Mailing Address - City: | AMERICAN CANYON |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94503-1340 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 328 KIMBERLY DR |
Practice Address - Street 2: | |
Practice Address - City: | AMERICAN CANYON |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94503-1340 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-643-4843 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-11-14 |
Last Update Date: | 2007-11-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 315P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 315P00000X | Nursing & Custodial Care Facilities | Intermediate Care Facility, Intellectual Disabilities |