MEDICARE: GRANITE BAY COUNTRYHOUSE LLC

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	:	1013802545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE BAY COUNTRYHOUSE LLC

Provider Business Mailing Address
First Line	:	8485 BARTON RD
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-9356
Country	:	US
Telephone Number	:	916-899-6565
Fax Number	:

Provider Business Practice Location Address
First Line	:	8485 BARTON RD
Second Line	:
City	:	GRANITE BAY
State	:	CA
Zip	:	95746-9356
Country	:	US
Telephone Number	:	916-899-6565
Fax Number	:

Authorized Official
Title or Position	:	VP ASSET MANAGEMENT
Name	:	STACY RANDELS
Credential	:
Telephone Number	:	531-800-3364

Provider Enumeration Date	:	06/12/2025
Last Update Date	:	06/12/2025

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