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General NPI Number Information
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NPI Number | 1346671344
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Entity Type | Organization
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Legal Business Name | HILLSTONE THERAPEUTIC TEAM OF NEVADA
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Dates
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Enumeration Date | 12/02/2013
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Last Update Date | 12/02/2013
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Provider Practice Location Address
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Address Line | 2971 N GATEWAY RD
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City | LAS VEGAS
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State | NV
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Zip | 89115-7452
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Country | US
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Telephone | 702-982-8398
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Fax | 702-982-8398
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Provider Business Mailing Address
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Address Line | 2971 N GATEWAY RD
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City | LAS VEGAS
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State | NV
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Zip | 89115-7452
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Country | US
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Telephone | 702-982-8398
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Fax | 702-982-8398
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. DOMINIQUE BLAKE BASS
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Credential | N/A
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Telephone | 702-300-0816
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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 | NV20131697710
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License Number State | NV
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