Healthcare Provider Details

I. General information

NPI: 1912090721
Provider Name (Legal Business Name): FAE OF FERNLEY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 US HIGHWAY 95A S SUITE D-401
FERNLEY NV
89408-9007
US

IV. Provider business mailing address

800 N RAINBOW BLVD SUITE 208
LAS VEGAS NV
89107-1189
US

V. Phone/Fax

Practice location:
  • Phone: 775-575-2320
  • Fax:
Mailing address:
  • Phone: 702-643-4443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROL J GRAHAM
Title or Position: PRESIDENT
Credential:
Phone: 702-203-5720