Healthcare Provider Details

I. General information

NPI: 1790136802
Provider Name (Legal Business Name): FAITH SHARI 3
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 LA ROCA CIR
LAS VEGAS NV
89121-6416
US

IV. Provider business mailing address

4504 LA ROCA CIR
LAS VEGAS NV
89121-6416
US

V. Phone/Fax

Practice location:
  • Phone: 702-856-6443
  • Fax:
Mailing address:
  • Phone: 702-856-6443
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number5893
License Number StateNV

VIII. Authorized Official

Name: FAITH SHARI RAMOS
Title or Position: ADMINISTRATION
Credential: RFA
Phone: 702-856-6443