Provider Demographics
NPI:1558512723
Name:GRAND VICTORIAN OF STERLING MASTER LESSEE, LLC
Entity Type:Organization
Organization Name:GRAND VICTORIAN OF STERLING MASTER LESSEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-747-3373
Mailing Address - Street 1:78 CENTENNIAL LOOP
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7900
Mailing Address - Country:US
Mailing Address - Phone:541-747-3373
Mailing Address - Fax:541-868-8447
Practice Address - Street 1:2705 AVENUE E
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:IL
Practice Address - Zip Code:61081-9016
Practice Address - Country:US
Practice Address - Phone:815-622-2800
Practice Address - Fax:815-622-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service