MEDICARE: DYNASTY VALLEY, 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	282E00000X	Long Term Care Hospital

General Provider Information

NPI Number	:	1427539998
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNASTY VALLEY, LLC

Provider Business Mailing Address
First Line	:	330 S MEDIO DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90049-3914
Country	:	US
Telephone Number	:	310-270-6469
Fax Number	:

Provider Business Practice Location Address
First Line	:	121 DORSEY DR
Second Line	:
City	:	GRASS VALLEY
State	:	CA
Zip	:	95945-5201
Country	:	US
Telephone Number	:	530-273-1316
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	NICHOLE TONS
Credential	:
Telephone Number	:	310-270-6469

Provider Enumeration Date	:	08/23/2018
Last Update Date	:	07/11/2023

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Directions to “DYNASTY VALLEY, LLC ” Practice Location

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