Healthcare Provider Details

I. General information

NPI: 1427539998
Provider Name (Legal Business Name): DYNASTY VALLEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 DORSEY DR
GRASS VALLEY CA
95945-5201
US

IV. Provider business mailing address

4076 LARK ST
SAN DIEGO CA
92103-1735
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-1316
  • Fax:
Mailing address:
  • Phone: 310-270-6469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: NICHOLE TONS
Title or Position: CEO
Credential:
Phone: 310-270-6469