Healthcare Provider Details

I. General information

NPI: 1053879247
Provider Name (Legal Business Name): ADVANCE ADDICTION TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 S RAINBOW BLVD STE 304
LAS VEGAS NV
89146-6212
US

IV. Provider business mailing address

7040 LAREDO ST STE E
LAS VEGAS NV
89117-3044
US

V. Phone/Fax

Practice location:
  • Phone: 702-776-2482
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QR0800X
TaxonomyRecovery Care Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: EDWARD GAMBOA
Title or Position: CEO
Credential:
Phone: 702-776-2482