MEDICARE: HEALTH TO 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	253Z00000X	In Home Supportive Care Agency	8302PCS-0	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1619336864	OTHER	NV	NPI - PROVIDER TYPE 58
2	1568850204	OTHER	NV	NPI - PROVIDER TYPE 30

General Provider Information

NPI Number	:	1619323425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTH TO NEVADA, LLC

Provider Business Mailing Address
First Line	:	4346 CRIMSON TIDE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-0446
Country	:	US
Telephone Number	:	702-405-8392
Fax Number	:	702-489-3013

Provider Business Practice Location Address
First Line	:	4346 CRIMSON TIDE AVE
Second Line	:
City	:	N LAS VEGAS
State	:	NV
Zip	:	89031-0446
Country	:	US
Telephone Number	:	702-405-8392
Fax Number	:	702-489-3013

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	TYLER MICHAEL BANNISTER
Credential	:
Telephone Number	:	775-772-7551

Provider Enumeration Date	:	05/11/2016
Last Update Date	:	05/11/2016

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