# GRAND CANYON GROUP HOME LLC

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** GRAND CANYON GROUP HOME LLC
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1750254850
- **Legal business name:** GRAND CANYON GROUP HOME LLC
- **Authorized official:** CASSANDRA VIRGINIA SIMPSON RN (EXECUTIVE DIRECTOR)
- **Authorized official phone:** (813) 810-6844

## Contact information

- **Practice address:** 5208 CHERRY AVE, SEFFNER, FL 33584-4406
- **Practice address phone:** (813) 810-6844
- **Practice address fax:** (813) 862-1072
- **Mailing address:** PO BOX 963, VALRICO, FL 33595-0963
- **Mailing address phone:** (813) 810-6844
- **Mailing address fax:** (813) 862-1072

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 251B00000X | Case Management Agency | — | NULL | — |
| 251E00000X | Home Health Agency | — | NULL | — |
| 251J00000X | Nursing Care Agency | — | NULL | — |
| 251S00000X | Community/Behavioral Health Agency | — | NULL | — |
| 313M00000X | Nursing Facility/Intermediate Care Facility | — | NULL | — |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | — | NULL | — |
| 320700000X | Physical Disabilities Residential Treatment Facility | — | NULL | — |
| 320900000X | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility | — | NULL | — |
| 322D00000X | Emotionally Disturbed Childrens' Residential Treatment Facility | — | NULL | Yes |

## Other

- **Enumeration date:** 09/25/2025
- **Last updated:** 09/25/2025