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General NPI Number Information
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NPI Number | 1346809373
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Entity Type | Organization
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Legal Business Name | AMETHYST CARE HOME LLC
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Dates
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Enumeration Date | 06/12/2019
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Last Update Date | 06/12/2019
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Provider Practice Location Address
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Address Line | 3702 INTERNET AVE
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89031-4160
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Country | US
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Telephone | 702-702-4854
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Fax |
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Provider Business Mailing Address
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Address Line | 4150 CACKLING GOOSE DR
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City | NORTH LAS VEGAS
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State | NV
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Zip | 89084-2650
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Country | US
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Telephone | 702-807-7634
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | ROLANDO MANAGO
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Credential |
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Telephone | 702-807-7634
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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