Provider Demographics
NPI:1972151967
Name:GRAND VILLAGE IN HOME CARE
Entity Type:Organization
Organization Name:GRAND VILLAGE IN HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHALEITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:405-821-1806
Mailing Address - Street 1:1320 N ROCKWELL AVE APT B
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73127-3355
Mailing Address - Country:US
Mailing Address - Phone:405-821-1806
Mailing Address - Fax:
Practice Address - Street 1:1320 N ROCKWELL AVE APT B
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73127-3355
Practice Address - Country:US
Practice Address - Phone:405-821-1806
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health