MEDICARE: AVENUE L BEHAVIORAL HEALTH

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	320800000X	Mental Illness Community Based Residential Treatment Facility	NV20171259753	NV

General Provider Information

NPI Number	:	1497280960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AVENUE L BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	5489 WALTON HEATH AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2590
Country	:	US
Telephone Number	:	702-355-8773
Fax Number	:

Provider Business Practice Location Address
First Line	:	5489 WALTON HEATH AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2590
Country	:	US
Telephone Number	:	702-355-8773
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. SHYNTIA ALLEN
Credential	:
Telephone Number	:	702-355-8773

Provider Enumeration Date	:	04/21/2017
Last Update Date	:	04/21/2017

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