Healthcare Provider Details

I. General information

NPI: 1336907583
Provider Name (Legal Business Name): BEDROCK AT HOME NEVADA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2024
Last Update Date: 03/12/2024
Certification Date: 03/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W HORIZON RIDGE PKWY STE 204
HENDERSON NV
89012-4840
US

IV. Provider business mailing address

1700 W HORIZON RIDGE PKWY STE 204
HENDERSON NV
89012-4840
US

V. Phone/Fax

Practice location:
  • Phone: 702-779-0147
  • Fax:
Mailing address:
  • Phone: 702-779-0147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL INDEFENZO
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 818-281-3084