Provider Demographics
NPI:1508953662
Name:GRANITE HILLS HEALTHCARE, INC.
Entity Type:Organization
Organization Name:GRANITE HILLS HEALTHCARE, INC.
Other - Org Name:GRANITE HILLS CONVALESCENT HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEVOIR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-447-1020
Mailing Address - Street 1:1340 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-8501
Mailing Address - Country:US
Mailing Address - Phone:619-447-1020
Mailing Address - Fax:619-447-1024
Practice Address - Street 1:1340 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-8501
Practice Address - Country:US
Practice Address - Phone:619-447-1020
Practice Address - Fax:619-447-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZT05392IMedicaid
CA055392Medicare ID - Type Unspecified