MEDICARE: GRANNY'S COTTAGE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1568179091
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANNY'S COTTAGE

Provider Business Mailing Address
First Line	:	7717 DEANTON CT
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95610-2131
Country	:	US
Telephone Number	:	916-606-9670
Fax Number	:	916-729-9319

Provider Business Practice Location Address
First Line	:	7717 DEANTON CT
Second Line	:
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95610-2131
Country	:	US
Telephone Number	:	916-606-9670
Fax Number	:	916-729-9319

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. ADALBERTH SABINEL BANCU
Credential	:
Telephone Number	:	916-606-9670

Provider Enumeration Date	:	11/03/2022
Last Update Date	:	11/03/2022

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Directions to “GRANNY'S COTTAGE ” Practice Location

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