Provider Demographics
NPI:1720051295
Name:GRANCARE LLC
Entity type:Organization
Organization Name:GRANCARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF REIMBURSMENTS
Authorized Official - Prefix:MR
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBAINA
Authorized Official - Suffix:JR
Authorized Official - Credentials:BS
Authorized Official - Phone:305-892-1790
Mailing Address - Street 1:1320 20TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2034
Mailing Address - Country:US
Mailing Address - Phone:310-829-4301
Mailing Address - Fax:
Practice Address - Street 1:1320 20TH ST
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2034
Practice Address - Country:US
Practice Address - Phone:310-829-4301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAN/AMedicare UPIN
CA05-5540Medicare ID - Type Unspecified