Healthcare Provider Details

I. General information

NPI: 1902175144
Provider Name (Legal Business Name): CGL GROUP CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2011
Last Update Date: 12/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 ELIMINATOR DR
LAS VEGAS NV
89146-1136
US

IV. Provider business mailing address

1900 ELIMINATOR DR
LAS VEGAS NV
89146-1136
US

V. Phone/Fax

Practice location:
  • Phone: 702-823-3553
  • Fax: 702-823-3553
Mailing address:
  • Phone: 702-823-3553
  • Fax: 702-823-3553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTIAN CASTANEDA
Title or Position: PRESIDENT
Credential:
Phone: 917-496-8000