MEDICARE: CULTURATION INC.

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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility

General Provider Information

NPI Number	:	1255560314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CULTURATION INC.

Provider Business Mailing Address
First Line	:	4144 THOMAS PATRICK AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8942
Country	:	US
Telephone Number	:	702-487-3095
Fax Number	:	702-647-3714

Provider Business Practice Location Address
First Line	:	4144 THOMAS PATRICK AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-8942
Country	:	US
Telephone Number	:	702-487-3095
Fax Number	:	702-647-3714

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MS. SHETONYA FORDHAM
Credential	:
Telephone Number	:	702-574-1857

Provider Enumeration Date	:	07/10/2009
Last Update Date	:	07/10/2009

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