Healthcare Provider Details

I. General information

NPI: 1558198242
Provider Name (Legal Business Name): TRANQUILITY RECOVERY NV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 HARRISON DR STE 2
LAS VEGAS NV
89120-4402
US

IV. Provider business mailing address

5840 W CRAIG RD # 120-253
LAS VEGAS NV
89130-2561
US

V. Phone/Fax

Practice location:
  • Phone: 702-900-8341
  • Fax:
Mailing address:
  • Phone: 702-900-8341
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW KHUDAVERDYAN
Title or Position: OWNER
Credential:
Phone: 702-900-8341