Healthcare Provider Details

I. General information

NPI: 1447866801
Provider Name (Legal Business Name): STEADFAST BEHAVIORAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8612 COPPER KNOLL AVE
LAS VEGAS NV
89129-7649
US

IV. Provider business mailing address

8612 COPPER KNOLL AVE
LAS VEGAS NV
89129-7649
US

V. Phone/Fax

Practice location:
  • Phone: 323-338-6101
  • Fax:
Mailing address:
  • Phone: 323-338-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MA VICTORIA ESCARDA
Title or Position: MANAGING MEMBER
Credential: APRN
Phone: 323-338-6101