Provider Demographics
NPI:1104306109
Name:GRAND LIFE COMMUNITY SERVICES, LLC.
Entity type:Organization
Organization Name:GRAND LIFE COMMUNITY SERVICES, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:979-618-0331
Mailing Address - Street 1:3306 GRAND CANE LN
Mailing Address - Street 2:
Mailing Address - City:ROSENBERG
Mailing Address - State:TX
Mailing Address - Zip Code:77471-4879
Mailing Address - Country:US
Mailing Address - Phone:979-618-0331
Mailing Address - Fax:
Practice Address - Street 1:3306 GRAND CANE LN
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-4879
Practice Address - Country:US
Practice Address - Phone:979-618-0331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities