Provider Demographics
NPI:1588721591
Name:GRANDFATHER HOME COMMUNITY SERVICES FOR CHILDREN
Entity type:Organization
Organization Name:GRANDFATHER HOME COMMUNITY SERVICES FOR CHILDREN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:SWINKOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MSW
Authorized Official - Phone:828-898-5465
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:BANNER ELK
Mailing Address - State:NC
Mailing Address - Zip Code:28604-0098
Mailing Address - Country:US
Mailing Address - Phone:828-898-5465
Mailing Address - Fax:828-898-8513
Practice Address - Street 1:5560 STURMER PARK CIR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-1372
Practice Address - Country:US
Practice Address - Phone:828-898-5465
Practice Address - Fax:828-898-8513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-034-015320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603668Medicaid