1568929198 NPI number — CLEAR CHOICE THERAPEUTIC CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568929198 NPI number — CLEAR CHOICE THERAPEUTIC CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLEAR CHOICE THERAPEUTIC CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568929198
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3670 N RANCHO DR STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89130-3192
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-591-3055
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4079 NORTH RANCHO DRIVE, SUITE 160
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-591-3055
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
BASS
Authorized Official First Name:
TAMI
Authorized Official Middle Name:
VERNETTE
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
702-591-3055

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NV20191164353 . This is a "NV SECRETARY OF STATE" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".




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