Provider Demographics
NPI:1912997594
Name:GRUNDY LIFE CARE CORP
Entity Type:Organization
Organization Name:GRUNDY LIFE CARE CORP
Other - Org Name:HERITAGE HALL GRUNDY
Other - Org Type:Other Name
Authorized Official - Title/Position:CCO AND GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:540-774-4263
Mailing Address - Street 1:3131 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-6427
Mailing Address - Country:US
Mailing Address - Phone:540-774-4263
Mailing Address - Fax:540-774-0780
Practice Address - Street 1:RR 5 BOX 104
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-9504
Practice Address - Country:US
Practice Address - Phone:276-935-8144
Practice Address - Fax:276-935-2316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VANH2576314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA227207OtherANTHEM BCBS PPO ID
VA4952596Medicaid
VA070928800OtherFEDERAL BLACK LUNG ID
VA070928800OtherFEDERAL BLACK LUNG ID