Healthcare Provider Details

I. General information

NPI: 1356054019
Provider Name (Legal Business Name): BESPOKE TREATMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2022
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 W CHARLESTON BLVD STE 38
LAS VEGAS NV
89102-1934
US

IV. Provider business mailing address

12381 WILSHIRE BLVD STE 205
LOS ANGELES CA
90025-1063
US

V. Phone/Fax

Practice location:
  • Phone: 833-867-2329
  • Fax: 833-867-3757
Mailing address:
  • Phone: 833-867-2329
  • Fax: 833-867-3757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. THI HOANG
Title or Position: BUSINESS OFFICE REPRESENTATIVE
Credential:
Phone: 702-205-8232