Provider Demographics
NPI:1053579102
Name:GRANT MEMORIAL HOMECARE AND HOSPICE, LLC
Entity type:Organization
Organization Name:GRANT MEMORIAL HOMECARE AND HOSPICE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PROFFITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:337-233-1307
Mailing Address - Street 1:PO BOX 51266
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-1266
Mailing Address - Country:US
Mailing Address - Phone:337-233-1307
Mailing Address - Fax:337-233-5764
Practice Address - Street 1:100 HOSPITAL DRIVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-9409
Practice Address - Country:US
Practice Address - Phone:304-257-2005
Practice Address - Fax:304-257-2093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV16251G00000X
315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013853Medicaid
WV3810013879OtherMEDICAID - NURSING HOME
WV3810013879OtherMEDICAID - NURSING HOME