Provider Demographics
NPI:1770257669
Name:GRANNY NANNIES OF NORTH AMERICA LLC
Entity Type:Organization
Organization Name:GRANNY NANNIES OF NORTH AMERICA LLC
Other - Org Name:
Other - Org Type:
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 STE 300
Mailing Address - Street 2:
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 1:510 CO RD 466 SUITE 207 #F
Practice Address - Street 2:
Practice Address - City:LADY LAKE
Practice Address - State:FL
Practice Address - Zip Code:32159
Practice Address - Country:US
Practice Address - Phone:352-365-7866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675935104Medicaid