=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356842041
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COALDEL BEHAVIORAL HEALTH SERVICES L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2018
-----------------------------------------------------
Last Update Date | 03/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2690 AFRICAN VIOLET AVE
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89074-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-201-8508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2690 AFRICAN VIOLET AVE
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89074-1957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-201-8508
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH I ARCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-485-3555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------