Provider Demographics
NPI:1790069656
Name:GRAYSON ASSISTED LIVING FACILITY
Entity Type:Organization
Organization Name:GRAYSON ASSISTED LIVING FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:GRAYSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-417-4969
Mailing Address - Street 1:25 OLD TRAIL
Mailing Address - Street 2:3455 ST RT 75
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704
Mailing Address - Country:US
Mailing Address - Phone:304-972-0815
Mailing Address - Fax:304-972-0814
Practice Address - Street 1:25 OLD TRL
Practice Address - Street 2:3455 ST RT 75
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9281
Practice Address - Country:US
Practice Address - Phone:304-972-0815
Practice Address - Fax:304-972-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV507554310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility