=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417394792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WESTCARE NEVADA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2013
-----------------------------------------------------
Last Update Date | 05/28/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 315 RECORD ST STE 103
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89512-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-996-1970
-----------------------------------------------------
Fax | 775-786-2418
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 S MARTIN LUTHER KING BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89106-4313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-385-3642
-----------------------------------------------------
Fax | 702-924-2575
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | AMY ROUKIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-348-8811
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 276400000X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Hospital Unit
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------