Provider Demographics
NPI:1366431447
Name:GRANGE NURSING HOME
Entity type:Organization
Organization Name:GRANGE NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:STOREY
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:618-566-2183
Mailing Address - Street 1:901 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-1017
Mailing Address - Country:US
Mailing Address - Phone:618-566-2183
Mailing Address - Fax:618-566-4462
Practice Address - Street 1:901 N 10TH ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1017
Practice Address - Country:US
Practice Address - Phone:618-566-2183
Practice Address - Fax:618-566-4462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0014399314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========001Medicaid
145785Medicare ID - Type Unspecified