Healthcare Provider Details

I. General information

NPI: 1194340471
Provider Name (Legal Business Name): TRAC-B EXCHANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6114 W CHARLESTON BLVD
LAS VEGAS NV
89146-1127
US

IV. Provider business mailing address

6540 BRADLEY RD
LAS VEGAS NV
89131-2913
US

V. Phone/Fax

Practice location:
  • Phone: 702-840-6693
  • Fax:
Mailing address:
  • Phone: 702-840-6693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. CHELSI CHEATOM
Title or Position: PROGRAM MANAGER
Credential:
Phone: 702-840-6693