MEDICARE: THI OF NEVADA II AT DESERT LANE, 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	314000000X	Skilled Nursing Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447298088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THI OF NEVADA II AT DESERT LANE, LLC

Provider Business Mailing Address
First Line	:	920 RIDGEBROOK RD
Second Line	:
City	:	SPARKS
State	:	MD
Zip	:	21152-9390
Country	:	US
Telephone Number	:	410-773-1000
Fax Number	:	410-773-1321

Provider Business Practice Location Address
First Line	:	660 S MARTIN L KING BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89106-4413
Country	:	US
Telephone Number	:	702-382-5580
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NICOLE WILK
Credential	:
Telephone Number	:	702-382-5580

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	07/25/2019

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