Provider Demographics
NPI:1306812425
Name:GRANITE CITY HOME CARE SERVICES, LLC
Entity type:Organization
Organization Name:GRANITE CITY HOME CARE SERVICES, 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 1:9510 ORMSBY STATION RD
Mailing Address - Street 2:STE 300
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-4081
Mailing Address - Country:US
Mailing Address - Phone:502-891-1187
Mailing Address - Fax:502-891-8067
Practice Address - Street 1:2100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:GRANITE CITY
Practice Address - State:IL
Practice Address - Zip Code:62040-4713
Practice Address - Country:US
Practice Address - Phone:618-798-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1010199251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364460628004Medicaid
IN147729Medicare Oscar/Certification