Provider Demographics
NPI:1215374749
Name:GRANNY'S DOWNHOME CARE CENTER
Entity type:Organization
Organization Name:GRANNY'S DOWNHOME CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATSY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:907-357-5803
Mailing Address - Street 1:2200 E WOLVERINE CIR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-2708
Mailing Address - Country:US
Mailing Address - Phone:907-357-5803
Mailing Address - Fax:907-357-5813
Practice Address - Street 1:2200 E WOLVERINE CIR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-2708
Practice Address - Country:US
Practice Address - Phone:907-357-5803
Practice Address - Fax:907-357-5813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-23
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100513310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility