Provider Demographics
NPI:1760604664
Name:GRANNY NANNIES OF NORTH AMERICA LLC
Entity Type:Organization
Organization Name:GRANNY NANNIES OF NORTH AMERICA LLC
Other - Org Name:GRANNY NANNIES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:HODGSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-682-7758
Mailing Address - Street 1:1912 BOOTHE CIR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-6709
Mailing Address - Country:US
Mailing Address - Phone:407-682-7758
Mailing Address - Fax:407-682-4569
Practice Address - Street 1:1912 BOOTHE CIR
Practice Address - Street 2:SUITE 300
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-6709
Practice Address - Country:US
Practice Address - Phone:407-682-7758
Practice Address - Fax:407-682-4569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X
FLNR30210990251E00000X
FLNR3010096311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675935104Medicaid
FL675935100Medicaid
FL675935100Medicaid