Provider Demographics
NPI:1588549596
Name:GRAND RESORT & SPA LLC
Entity type:Organization
Organization Name:GRAND RESORT & SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-888-2694
Mailing Address - Street 1:41 PIPESTEM SPA WAY
Mailing Address - Street 2:
Mailing Address - City:PIPESTEM
Mailing Address - State:WV
Mailing Address - Zip Code:25979-8700
Mailing Address - Country:US
Mailing Address - Phone:304-922-7572
Mailing Address - Fax:
Practice Address - Street 1:41 PIPESTEM SPA WAY
Practice Address - Street 2:
Practice Address - City:PIPESTEM
Practice Address - State:WV
Practice Address - Zip Code:25979-8700
Practice Address - Country:US
Practice Address - Phone:304-922-7572
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-08
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821987850OtherMASSAGE THERAPY