Healthcare Provider Details

I. General information

NPI: 1316608797
Provider Name (Legal Business Name): SHORT TERM HOUSE 1 OF NV LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2022
Last Update Date: 01/06/2022
Certification Date: 01/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4417 ISABELLA AVE
LAS VEGAS NV
89110-4664
US

IV. Provider business mailing address

1600 E DESERT INN RD STE 104
LAS VEGAS NV
89169-2505
US

V. Phone/Fax

Practice location:
  • Phone: 702-205-8968
  • Fax:
Mailing address:
  • Phone: 702-208-2194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State

VIII. Authorized Official

Name: MAIMOUNA R CANTRALL
Title or Position: OWNER
Credential:
Phone: 702-208-2194