Healthcare Provider Details

I. General information

NPI: 1083167290
Provider Name (Legal Business Name): CHARLESTON RESIDENTIAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W CHARLESTON BLVD
LAS VEGAS NV
89102-2205
US

IV. Provider business mailing address

840 S RANCHO DR # 4-613
LAS VEGAS NV
89106-3837
US

V. Phone/Fax

Practice location:
  • Phone: 702-382-7746
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFFREY IVERSON
Title or Position: PRESIDENT
Credential:
Phone: 702-357-8811