Healthcare Provider Details

I. General information

NPI: 1568235893
Provider Name (Legal Business Name): TRANQUILITY RECOVERY NV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2023
Last Update Date: 01/19/2024
Certification Date: 01/19/2024
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

3870 E FLAMINGO RD # A2-525
LAS VEGAS NV
89121-6228
US

V. Phone/Fax

Practice location:
  • Phone: 702-900-8341
  • Fax: 702-549-7610
Mailing address:
  • Phone: 702-706-4969
  • Fax: 702-549-7610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2083T0002X
TaxonomyMedical Toxicology (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MATTHEW KHUDAVERDYAN
Title or Position: OWNER/CEO
Credential:
Phone: 702-900-8341