Healthcare Provider Details

I. General information

NPI: 1790063626
Provider Name (Legal Business Name): APPLE GROVE TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2011
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3155 E PATRICK LN STE 1
LAS VEGAS NV
89120-3481
US

IV. Provider business mailing address

3155 E PATRICK LN STE 1
LAS VEGAS NV
89120-3481
US

V. Phone/Fax

Practice location:
  • Phone: 702-992-0576
  • Fax: 702-992-0391
Mailing address:
  • Phone: 702-992-0576
  • Fax: 702-992-0391

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 Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ICIA SANDULAK
Title or Position: DIRECTOR
Credential:
Phone: 702-576-7942