Healthcare Provider Details

I. General information

NPI: 1841654100
Provider Name (Legal Business Name): GRANDMOTHER'S CRIB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 SIENNA STATION WAY
RENO NV
89512-1363
US

IV. Provider business mailing address

700 SIENNA STATION WAY
RENO NV
89512-1363
US

V. Phone/Fax

Practice location:
  • Phone: 775-470-5313
  • Fax: 775-470-5191
Mailing address:
  • Phone: 775-470-5313
  • Fax: 775-470-5191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number5703AGC-12
License Number StateNV

VIII. Authorized Official

Name: EVANGELINE BELTEJAR-DIFUNTORUM
Title or Position: OWNER
Credential:
Phone: 775-530-5745