Provider Demographics
NPI:1457853798
Name:GRANT COMMUNITY RESIDENTIAL HOME
Entity Type:Organization
Organization Name:GRANT COMMUNITY RESIDENTIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AHCA PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAHPHET
Authorized Official - Middle Name:Y
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-935-9247
Mailing Address - Street 1:2252 WRIGHT STREET (A)
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916
Mailing Address - Country:US
Mailing Address - Phone:239-935-9247
Mailing Address - Fax:239-466-0142
Practice Address - Street 1:2252 WRIGHT STREET (A)
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916
Practice Address - Country:US
Practice Address - Phone:239-935-9247
Practice Address - Fax:239-466-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2018-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty