Provider Demographics
NPI:1649242876
Name:GRUNDY COUNTY NURSING HOME
Entity type:Organization
Organization Name:GRUNDY COUNTY NURSING HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-359-5647
Mailing Address - Street 1:1311 E 28TH ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:64683
Mailing Address - Country:US
Mailing Address - Phone:660-359-5647
Mailing Address - Fax:660-359-4111
Practice Address - Street 1:1311 E 28TH ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MO
Practice Address - Zip Code:64683
Practice Address - Country:US
Practice Address - Phone:660-359-5647
Practice Address - Fax:660-359-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
035512314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101496404Medicaid
91044019OtherBCBS
MO0624920001Medicare NSC
MO101496404Medicaid