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General NPI Number Information
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NPI Number | 1164097556
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Entity Type | Organization
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Legal Business Name | RADICAL ELEVATION
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Dates
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Enumeration Date | 05/26/2021
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Last Update Date | 09/23/2024
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Provider Practice Location Address
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Address Line | 3551 E BONANZA RD STE 101
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City | LAS VEGAS
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State | NV
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Zip | 89110-2198
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Country | US
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Telephone | 702-482-7441
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Fax |
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Provider Business Mailing Address
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Address Line | 3551 E BONANZA RD STE 101
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City | LAS VEGAS
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State | NV
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Zip | 89110-2198
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Country | US
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Telephone | 702-482-7441
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. BRIAN HARGE
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Credential | CVA
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Telephone | 702-423-2703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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