Provider Demographics
NPI:1609099134
Name:AMERICAN MASTERS VILLAGE
Entity Type:Organization
Organization Name:AMERICAN MASTERS VILLAGE
Other - Org Name:GRAYSON HOUSE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEANNA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:413-426-9868
Mailing Address - Street 1:942 GRAYSON DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01119-1547
Mailing Address - Country:US
Mailing Address - Phone:413-426-9868
Mailing Address - Fax:413-426-9651
Practice Address - Street 1:942 GRAYSON DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01119-1547
Practice Address - Country:US
Practice Address - Phone:413-426-9868
Practice Address - Fax:413-426-9651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1906348Medicaid