Organization · NPI-2

Grand Canyon Group Home LLC

In Home Supportive Care · Valrico, FL

NPI number1477278232

StatusActive

Last updated in NPPESOct 4, 2022

Details

NPI: 1477278232
Entity type: Organization (NPI-2)
Legal business name: Grand Canyon Group Home LLC
Organization subpart: No
Enumeration date: Oct 4, 2022
Certification date: Oct 4, 2022
Last updated: Oct 4, 2022

Taxonomy and licenses

Taxonomy code	Description	License	State	Primary
253Z00000X	In Home Supportive Care	–	–	Yes
251E00000X	Home Health	–	–
251J00000X	Nursing Care	–	–
261QD1600X	Clinic/Center, Developmental Disabilities	–	–
261QH0100X	Clinic/Center, Health Services	–	–
385HR2060X	Respite Care, Respite Care, Intellectual and/or Developmental Disabilities, Child	–	–

Practice location

949 Grand Canyon Dr
Valrico, FL 33594-4351

Phone 813-530-0004 · Fax 813-862-1072

Mailing address

Po Box 963
Valrico, FL 33595-0963

Phone 813-530-0004 · Fax 813-862-1072

Authorized official

Cassandra Virginia Simpson
Director
8138106844

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