Provider Demographics
NPI:1366637027
Name:THE GRAND RIVER HEALTH SYSTEM CORPORATION
Entity Type:Organization
Organization Name:THE GRAND RIVER HEALTH SYSTEM CORPORATION
Other - Org Name:HEDRICK MEDICAL CENTER HOME HEALTH AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-646-1480
Mailing Address - Street 1:498 PARK LN
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:MO
Mailing Address - Zip Code:64601-1551
Mailing Address - Country:US
Mailing Address - Phone:660-646-2199
Mailing Address - Fax:
Practice Address - Street 1:498 PARK LN
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:MO
Practice Address - Zip Code:64601-1551
Practice Address - Country:US
Practice Address - Phone:660-646-2199
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE GRAND RIVER HEALTH SYSTEM CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-06
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO8325376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO281965301Medicaid