Healthcare Provider Details

I. General information

NPI: 1861834186
Provider Name (Legal Business Name): LIONS CREST L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2013
Last Update Date: 10/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 W SAHARA AVE STE 102-2
LAS VEGAS NV
89146-0394
US

IV. Provider business mailing address

5420 W SAHARA AVE STE 102-2
LAS VEGAS NV
89146-0394
US

V. Phone/Fax

Practice location:
  • Phone: 702-485-5050
  • Fax: 702-485-5207
Mailing address:
  • Phone: 702-485-5050
  • Fax: 702-485-5207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MR. WASCAR CRUZ
Title or Position: OWNER
Credential:
Phone: 702-485-5050