Healthcare Provider Details

I. General information

NPI: 1902485113
Provider Name (Legal Business Name): SMART START INDEPENDENT LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 W HORIZON RIDGE PKWY # R579
HENDERSON NV
89012-3600
US

IV. Provider business mailing address

1550 W HORIZON RIDGE PKWY # R579
HENDERSON NV
89012-3600
US

V. Phone/Fax

Practice location:
  • Phone: 760-596-5999
  • Fax:
Mailing address:
  • Phone: 760-596-5999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DONNA MCCALL MYLES
Title or Position: OWNER/MANAGER
Credential:
Phone: 760-596-5999