Healthcare Provider Details

I. General information

NPI: 1265078273
Provider Name (Legal Business Name): HORIZON RIDGE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 02/16/2024
Certification Date: 02/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 S FLAMINGO RD SUITE A
LAS VEGAS NV
89119-6002
US

IV. Provider business mailing address

1670 S FLAMINGO RD SUITE A
LAS VEGAS NV
89119-6002
US

V. Phone/Fax

Practice location:
  • Phone: 702-489-2889
  • Fax: 702-780-0755
Mailing address:
  • Phone: 702-489-2889
  • Fax: 702-780-0755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State

VIII. Authorized Official

Name: BRUCE ANTHONY EDDINS
Title or Position: CHIEF ADMINISTRATOR
Credential:
Phone: 702-489-2889