MEDICARE: DIVERSIFIED COALITION 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	101Y00000X	Counselor		NV

General Provider Information

NPI Number	:	1083919328
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVERSIFIED COALITION LLC

Provider Business Mailing Address
First Line	:	2340 PASEO DEL PRADO
Second Line	:	BUILDING D SUITE 206
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4360
Country	:	US
Telephone Number	:	702-485-2121
Fax Number	:

Provider Business Practice Location Address
First Line	:	2340 PASEO DEL PRADO
Second Line	:	BUILDING D SUITE 206
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4360
Country	:	US
Telephone Number	:	702-485-2121
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED AGENT
Name	:	MS. MYRNA T PILI
Credential	:	MBA
Telephone Number	:	702-569-4455

Provider Enumeration Date	:	01/18/2011
Last Update Date	:	01/18/2011

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