MEDICARE: HEALTHY LIFESTYLE RESIDENCE, 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	310400000X	Assisted Living Facility	5880AGC-0	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9005055957	OTHER	NV	ATYPICAL PROVIDER IDENTIFIER NEVADA DIVISION OF HEALTHCARE FINANCING AND POLICY

General Provider Information

NPI Number	:	1780903872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY LIFESTYLE RESIDENCE, LLC

Provider Business Mailing Address
First Line	:	3990 LAKESIDE DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89509-5336
Country	:	US
Telephone Number	:	775-828-5151
Fax Number	:	775-828-5152

Provider Business Practice Location Address
First Line	:	3990 LAKESIDE DR
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89509-5336
Country	:	US
Telephone Number	:	775-828-5151
Fax Number	:	775-828-5152

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. FELICISIMA A. GRAHAM
Credential	:	RFA
Telephone Number	:	775-828-5151

Provider Enumeration Date	:	05/27/2010
Last Update Date	:	05/27/2010

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