Provider Demographics
NPI:1457678625
Name:GRENADA NORTH DELTA HOSPICE & PALLIATIVE SERVICES, LLC
Entity Type:Organization
Organization Name:GRENADA NORTH DELTA HOSPICE & PALLIATIVE SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:E
Authorized Official - Last Name:VALLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-393-0170
Mailing Address - Street 1:123 STATELINE RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-1710
Mailing Address - Country:US
Mailing Address - Phone:662-393-0170
Mailing Address - Fax:662-393-0171
Practice Address - Street 1:141 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DREW
Practice Address - State:MS
Practice Address - Zip Code:38737-3406
Practice Address - Country:US
Practice Address - Phone:662-745-0587
Practice Address - Fax:662-745-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS132251G00000X
MS137251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS251629Medicare Oscar/Certification
MS251626Medicare Oscar/Certification