Provider Demographics
NPI:1720038425
Name:GRENADA REHABILITATION AND HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:GRENADA REHABILITATION AND HEALTHCARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-626-0000
Mailing Address - Street 1:1966 HILL DR
Mailing Address - Street 2:
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-5047
Mailing Address - Country:US
Mailing Address - Phone:662-226-2442
Mailing Address - Fax:662-226-9567
Practice Address - Street 1:1966 HILL DR
Practice Address - Street 2:
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-5047
Practice Address - Country:US
Practice Address - Phone:662-226-2442
Practice Address - Fax:662-226-9567
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARK MISSISSIPPI HOLDING COMPANY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-11
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS503314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS230070Medicaid
MS230070Medicaid