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NPI Code Detail

MEDICARE: CHARLESTON PEDIATRIC SNF LLC

MEDICARE: CHARLESTON PEDIATRIC SNF 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1205504917
Entity Type Code : Organization
Provider Name (Legal Business Name) : CHARLESTON PEDIATRIC SNF LLC
Provider Business Mailing Address
First Line : 2496 W CHARLESTON BLVD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89102-2179
Country : US
Telephone Number : 702-310-3720
Fax Number : 702-310-3722
Provider Business Practice Location Address
First Line : 2496 W CHARLESTON BLVD
Second Line :
City : LAS VEGAS
State : NV
Zip : 89102-2179
Country : US
Telephone Number : 702-310-3720
Fax Number : 702-310-3722
Authorized Official
Title or Position : CEO
Name : MR. DANIEL EVANS MATHIS
Credential :
Telephone Number : 702-310-3720
Provider Enumeration Date : 08/30/2021
Last Update Date : 02/13/2025

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Directions to “CHARLESTON PEDIATRIC SNF LLC ” Practice Location

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