Provider Demographics
NPI:1598000705
Name:GRAND 14 LLC
Entity Type:Organization
Organization Name:GRAND 14 LLC
Other - Org Name:SOMEPLACE LIKE HOME ALF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLEMETSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-931-5599
Mailing Address - Street 1:10109 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-7350
Mailing Address - Country:US
Mailing Address - Phone:813-931-5599
Mailing Address - Fax:813-931-4440
Practice Address - Street 1:10109 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7350
Practice Address - Country:US
Practice Address - Phone:813-931-5599
Practice Address - Fax:813-931-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL10036310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility