MEDICARE: FAMILY FRIENDLY CARE HOME 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	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1578264685
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY FRIENDLY CARE HOME LLC

Provider Business Mailing Address
First Line	:	3784 EDISON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3407
Country	:	US
Telephone Number	:	702-586-0710
Fax Number	:	702-586-0710

Provider Business Practice Location Address
First Line	:	3784 EDISON AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-3407
Country	:	US
Telephone Number	:	702-586-0710
Fax Number	:	702-586-0710

Authorized Official
Title or Position	:	MANAGER
Name	:	DIRK BENEDICT MAYANDIA
Credential	:
Telephone Number	:	702-782-7265

Provider Enumeration Date	:	03/15/2023
Last Update Date	:	01/09/2026

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