MEDICARE: GRANITE VIEW ADULT 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	310400000X	Assisted Living Facility	AL8343H	AZ

General Provider Information

NPI Number	:	1972005395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GRANITE VIEW ADULT CARE HOME LLC

Provider Business Mailing Address
First Line	:	PO BOX 11805
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86304
Country	:	US
Telephone Number	:	928-778-0002
Fax Number	:	928-778-1207

Provider Business Practice Location Address
First Line	:	7105 WILLIAMSON VALLEY ROAD
Second Line	:
City	:	PRESCOTT
State	:	AZ
Zip	:	86305
Country	:	US
Telephone Number	:	928-778-0002
Fax Number	:	928-778-1207

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. KAREN S JONES
Credential	:
Telephone Number	:	928-533-4472

Provider Enumeration Date	:	03/01/2018
Last Update Date	:	03/01/2018

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