Healthcare Provider Details

I. General information

NPI: 1902770308
Provider Name (Legal Business Name): GRANVILLE ASSISTED LIVING - PARADISE RETREAT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2025
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 N DOLAN CT
PRESCOTT VALLEY AZ
86314-6753
US

IV. Provider business mailing address

5420 N DOLAN CT
PRESCOTT VALLEY AZ
86314-6753
US

V. Phone/Fax

Practice location:
  • Phone: 626-464-4379
  • Fax:
Mailing address:
  • Phone: 626-464-4379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: GERALD ANTHONY MARTIN
Title or Position: OWNER
Credential: MASTER'S DEGREE
Phone: 626-464-4379