Provider Demographics
NPI:1710371539
Name:73 NORTH OF GRANVILLE, INC.
Entity Type:Organization
Organization Name:73 NORTH OF GRANVILLE, INC.
Other - Org Name:HOLBROOK ADULT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:HOLLISTER
Authorized Official - Last Name:PAUQUETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-642-3476
Mailing Address - Street 1:73 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:GRANVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12832-1136
Mailing Address - Country:US
Mailing Address - Phone:518-642-3476
Mailing Address - Fax:518-642-3801
Practice Address - Street 1:73 NORTH ST
Practice Address - Street 2:
Practice Address - City:GRANVILLE
Practice Address - State:NY
Practice Address - Zip Code:12832-1136
Practice Address - Country:US
Practice Address - Phone:518-642-3476
Practice Address - Fax:518-642-3801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY760-F-014311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home