Provider Demographics
NPI:1316240195
Name:GREAT GRANDMA'S TENDER, LOVE AND CARE, INC
Entity type:Organization
Organization Name:GREAT GRANDMA'S TENDER, LOVE AND CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-583-3876
Mailing Address - Street 1:34729 ORCHID PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGE MANOR
Mailing Address - State:FL
Mailing Address - Zip Code:33523-8864
Mailing Address - Country:US
Mailing Address - Phone:352-583-3876
Mailing Address - Fax:352-583-3876
Practice Address - Street 1:34729 ORCHID PKWY
Practice Address - Street 2:
Practice Address - City:RIDGE MANOR
Practice Address - State:FL
Practice Address - Zip Code:33523-8864
Practice Address - Country:US
Practice Address - Phone:352-583-3876
Practice Address - Fax:352-583-3876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL693102296251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL231539OtherACHA
FL693102296Medicaid
FL693102201Medicaid
FL693102298Medicaid