Basic Information
| Provider Information | |||||||||
| NPI: | 1891024642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GRACE HEALTH & REHAB OF GRENADA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1966 HILL DR | ||||||||
| Address2: | |||||||||
| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389015047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622262442 | ||||||||
| FaxNumber: | 6622269567 | ||||||||
| Practice Location | |||||||||
| Address1: | 1966 HILL DR | ||||||||
| Address2: | |||||||||
| City: | GRENADA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389015047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622262442 | ||||||||
| FaxNumber: | 6622269567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2009 | ||||||||
| LastUpdateDate: | 04/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | MURPHY | ||||||||
| AuthorizedOfficialFirstName: | ADRIENNE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9019377994 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COVENANT DOVE, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 225X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 09238334 | 05 | MS | MEDICAID |