MEDICARE: GRANNY'S HOUSE OF HEALING, INC

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1740526250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANNY'S HOUSE OF HEALING, INC

Provider Business Mailing Address
First Line	:	6509 CHATTERER ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-2254
Country	:	US
Telephone Number	:	702-628-4783
Fax Number	:	702-924-1264

Provider Business Practice Location Address
First Line	:	6509 CHATTERER ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-2254
Country	:	US
Telephone Number	:	702-628-4783
Fax Number	:	702-924-1264

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DORETHA SCOTT
Credential	:
Telephone Number	:	702-628-4783

Provider Enumeration Date	:	01/02/2013
Last Update Date	:	01/02/2013

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