Provider Demographics
NPI:1174673933
Name:GRANDVIEW VILLA ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:GRANDVIEW VILLA ASSISTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER-MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-757-0136
Mailing Address - Street 1:2544 GRANDVIEW CIR SW
Mailing Address - Street 2:
Mailing Address - City:LENOIR
Mailing Address - State:NC
Mailing Address - Zip Code:28645-9638
Mailing Address - Country:US
Mailing Address - Phone:828-757-0136
Mailing Address - Fax:828-757-0213
Practice Address - Street 1:2544 GRANDVIEW CIR SW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-9638
Practice Address - Country:US
Practice Address - Phone:828-757-0136
Practice Address - Fax:828-757-0213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHAL-014-015310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805628Medicaid