Provider Demographics
NPI:1750254850
Name:GRAND CANYON GROUP HOME LLC
Entity type:Organization
Organization Name:GRAND CANYON GROUP HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:VIRGINIA
Authorized Official - Last Name:SIMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:813-810-6844
Mailing Address - Street 1:PO BOX 963
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33595-0963
Mailing Address - Country:US
Mailing Address - Phone:813-810-6844
Mailing Address - Fax:813-862-1072
Practice Address - Street 1:5208 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-4406
Practice Address - Country:US
Practice Address - Phone:813-810-6844
Practice Address - Fax:813-862-1072
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND CANYON GROUP HOME LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities