MEDICARE: RECOVERY INSTITUTE OF NEVADA 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1144708694
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RECOVERY INSTITUTE OF NEVADA LLC

Provider Business Mailing Address
First Line	:	1771 E FLAMINGO RD STE 112B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-0851
Country	:	US
Telephone Number	:	702-405-9559
Fax Number	:

Provider Business Practice Location Address
First Line	:	1771 E FLAMINGO RD STE 112B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-0851
Country	:	US
Telephone Number	:	702-405-9559
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES SIMBULAN
Credential	:
Telephone Number	:	702-405-9559

Provider Enumeration Date	:	08/06/2018
Last Update Date	:	12/13/2018

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