Healthcare Provider Details

I. General information

NPI: 1528427614
Provider Name (Legal Business Name): INTERNATIONAL ADULT DAY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 RENAISSANCE DR STE A
LAS VEGAS NV
89119-6163
US

IV. Provider business mailing address

2215 RENAISSANCE DR STE A
LAS VEGAS NV
89119-6163
US

V. Phone/Fax

Practice location:
  • Phone: 702-405-6393
  • Fax: 702-405-6564
Mailing address:
  • Phone: 702-405-6393
  • Fax: 702-405-6564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number2014159531
License Number StateNV

VIII. Authorized Official

Name: MRS. DELIA R GONZALEZ
Title or Position: CREDENTIALING/BILLING
Credential: M.A
Phone: 702-258-4900