=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083191738
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A ROYAL BEHAVIORAL AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2018
-----------------------------------------------------
Last Update Date | 10/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2595 S CIMARRON RD STE 107
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-596-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2595 S CIMARRON RD STE 107
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89117-2697
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-430-7987
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PROVIDER
-----------------------------------------------------
Name | ELIZABETH GARCIA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-430-7987
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | NV20181514587
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------