Healthcare Provider Details

I. General information

NPI: 1790829828
Provider Name (Legal Business Name): VEGAS ASSISTED LIVING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6031 CHEYENNE AVE
LAS VEGAS NV
89108-4200
US

IV. Provider business mailing address

PO BOX 3006
SALEM OR
97302-0006
US

V. Phone/Fax

Practice location:
  • Phone: 702-658-5882
  • Fax:
Mailing address:
  • Phone: 503-375-9016
  • Fax: 503-485-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2089AGC-21
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number2089AGC-16
License Number StateNV

VIII. Authorized Official

Name: MR. JON M HARDER
Title or Position: MANAGER
Credential:
Phone: 503-375-9016