Provider Demographics
NPI:1780765131
Name:GRANGER VILLA INC
Entity type:Organization
Organization Name:GRANGER VILLA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:BARTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-964-7053
Mailing Address - Street 1:PO BOX 398
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:TX
Mailing Address - Zip Code:76530-0398
Mailing Address - Country:US
Mailing Address - Phone:512-859-2800
Mailing Address - Fax:512-859-2905
Practice Address - Street 1:800 N COMMERCE
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:TX
Practice Address - Zip Code:76530-0398
Practice Address - Country:US
Practice Address - Phone:512-859-2800
Practice Address - Fax:512-859-2905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118542314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001003004Medicaid
TX001003004Medicaid