Provider Demographics
NPI:1871635888
Name:DOROTHY FAYE ALEXANDER
Entity Type:Organization
Organization Name:DOROTHY FAYE ALEXANDER
Other - Org Name:GRANNY'S HOUSE - MAGNOLIA RD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER LICENSEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-589-0536
Mailing Address - Street 1:350 PLUMAS DR
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-9241
Mailing Address - Country:US
Mailing Address - Phone:530-589-0536
Mailing Address - Fax:530-589-1602
Practice Address - Street 1:632 MAGNOLIA RD
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-3008
Practice Address - Country:US
Practice Address - Phone:530-589-0536
Practice Address - Fax:530-589-1602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC60994FOtherCA MEDI CAL VENDOR #
CA55-G421Medicare ID - Type Unspecified