Provider Demographics
NPI:1386636033
Name:GRAND BAY CONVALESCENT HOME INC
Entity Type:Organization
Organization Name:GRAND BAY CONVALESCENT HOME INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-865-6443
Mailing Address - Street 1:PO BOX 328
Mailing Address - Street 2:
Mailing Address - City:GRAND BAY
Mailing Address - State:AL
Mailing Address - Zip Code:36541-0328
Mailing Address - Country:US
Mailing Address - Phone:251-865-6443
Mailing Address - Fax:251-865-3610
Practice Address - Street 1:13750 HIGHWAY 90 WEST
Practice Address - Street 2:
Practice Address - City:GRAND BAY
Practice Address - State:AL
Practice Address - Zip Code:36541
Practice Address - Country:US
Practice Address - Phone:251-865-6443
Practice Address - Fax:251-865-3610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10610314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4752110SMedicaid
AL015406Medicare ID - Type Unspecified