Provider Demographics
NPI:1629375209
Name:GRANDPA & GRANDMA PRIMARY HOME CARE
Entity Type:Organization
Organization Name:GRANDPA & GRANDMA PRIMARY HOME CARE
Other - Org Name:GRANDPA & GRANDMA PRIMARY HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:DE LEON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:956-589-6813
Mailing Address - Street 1:123 OLD PORT ISABEL RD STE A5
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78521
Mailing Address - Country:US
Mailing Address - Phone:956-589-6813
Mailing Address - Fax:956-554-7336
Practice Address - Street 1:123 OLD PORT ISABEL RD STE A5
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78521-3542
Practice Address - Country:US
Practice Address - Phone:956-554-9829
Practice Address - Fax:956-554-7336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-17
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living FacilityGroup - Single Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1032518Medicaid