Provider Demographics
NPI:1578879920
Name:GRAND RIVER RESIDENTIAL SERVICES LLC
Entity Type:Organization
Organization Name:GRAND RIVER RESIDENTIAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:QUICK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:816-507-6609
Mailing Address - Street 1:28105 S BUFORD RD
Mailing Address - Street 2:
Mailing Address - City:HARRISONVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64701-8325
Mailing Address - Country:US
Mailing Address - Phone:816-507-6609
Mailing Address - Fax:
Practice Address - Street 1:28105 S BUFORD RD
Practice Address - Street 2:
Practice Address - City:HARRISONVILLE
Practice Address - State:MO
Practice Address - Zip Code:64701-8325
Practice Address - Country:US
Practice Address - Phone:816-507-6609
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities