Provider Demographics
NPI:1568702256
Name:GRAND ANNE RESIDENCES, LLC
Entity Type:Organization
Organization Name:GRAND ANNE RESIDENCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:Z
Authorized Official - Last Name:SHAFER
Authorized Official - Suffix:
Authorized Official - Credentials:QRMP
Authorized Official - Phone:540-261-2222
Mailing Address - Street 1:2104 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BUENA VISTA
Mailing Address - State:VA
Mailing Address - Zip Code:24416-2738
Mailing Address - Country:US
Mailing Address - Phone:540-261-2222
Mailing Address - Fax:540-261-2222
Practice Address - Street 1:2104 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:VA
Practice Address - Zip Code:24416-2738
Practice Address - Country:US
Practice Address - Phone:540-261-2222
Practice Address - Fax:540-261-2222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-18
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1952320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1952OtherDBHDS