# GRAND CANYON GROUP HOME LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1477278232
- **Authorized official:** CASSANDRA VIRGINIA SIMPSON BSN, RN (DIRECTOR)
- **Authorized official phone:** (813) 810-6844

## Contact information

- **Practice address:** 949 GRAND CANYON DR, VALRICO, FL 33594-4351
- **Practice address phone:** (813) 530-0004
- **Practice address fax:** (813) 862-1072
- **Mailing address:** PO BOX 963, VALRICO, FL 33595-0963
- **Mailing address phone:** (813) 530-0004
- **Mailing address fax:** (813) 862-1072

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251E00000X | Home Health Agency | — | NULL | — |
| 251J00000X | Nursing Care Agency | — | NULL | — |
| 253Z00000X | In Home Supportive Care Agency | — | NULL | Yes |
| 261QD1600X | Developmental Disabilities Clinic/Center | — | NULL | — |
| 261QH0100X | Health Service Clinic/Center | — | NULL | — |
| 385HR2060X | Child Intellectual and/or Developmental Disabilities Respite Care | — | NULL | — |

## Other

- **Enumeration date:** 10/04/2022
- **Last updated:** 10/04/2022