Provider Demographics
NPI:1528481678
Name:GRANDSLAM RESIDENTIAL, LLC
Entity type:Organization
Organization Name:GRANDSLAM RESIDENTIAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-691-9178
Mailing Address - Street 1:14012 ROCKHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-9721
Mailing Address - Country:US
Mailing Address - Phone:804-691-9178
Mailing Address - Fax:
Practice Address - Street 1:14012 ROCKHAVEN DR
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23836-9721
Practice Address - Country:US
Practice Address - Phone:804-691-9178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-26
Last Update Date:2014-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2194320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities