MEDICARE: FAE OF FERNLEY, 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	3104A0630X	Assisted Living Facility (Behavioral Disturbances)

General Provider Information

NPI Number	:	1912090721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAE OF FERNLEY, INC.

Provider Business Mailing Address
First Line	:	800 N RAINBOW BLVD
Second Line	:	SUITE 208
City	:	LAS VEGAS
State	:	NV
Zip	:	89107-1189
Country	:	US
Telephone Number	:	702-643-4443
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 US HIGHWAY 95A S
Second Line	:	SUITE D-401
City	:	FERNLEY
State	:	NV
Zip	:	89408-9007
Country	:	US
Telephone Number	:	775-575-2320
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. CAROL J GRAHAM
Credential	:
Telephone Number	:	702-203-5720

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	08/22/2020

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