Healthcare Provider Details

I. General information

NPI: 1417738170
Provider Name (Legal Business Name): OCEAN BREEZE CARE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4115 E COLORADO AVE
LAS VEGAS NV
89104-5107
US

IV. Provider business mailing address

4115 E COLORADO AVE
LAS VEGAS NV
89104-5107
US

V. Phone/Fax

Practice location:
  • Phone: 702-493-5998
  • Fax: 702-552-9525
Mailing address:
  • Phone: 725-373-3732
  • Fax: 702-552-9525

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 Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name: LYNN KELLY
Title or Position: OWNER
Credential:
Phone: 702-473-0818