Provider Demographics
NPI:1477501922
Name:COMMUNITY CARE CENTER OF GRENADA, LLC
Entity Type:Organization
Organization Name:COMMUNITY CARE CENTER OF GRENADA, LLC
Other - Org Name:GRENADA LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:PARKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-709-1408
Mailing Address - Street 1:1950 GRANDVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-1674
Mailing Address - Country:US
Mailing Address - Phone:662-226-9554
Mailing Address - Fax:662-226-5537
Practice Address - Street 1:1950 GRANDVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-1674
Practice Address - Country:US
Practice Address - Phone:662-226-9554
Practice Address - Fax:662-226-5537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS413314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS80428OtherBLUE CROSS BLUE SHIELD
MS00230187Medicaid
MS255104Medicare Oscar/Certification