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General NPI Number Information
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NPI Number | 1457815961
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Entity Type | Organization
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Legal Business Name | HOUSE OF CHAMPIONS USA LLC
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Dates
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Enumeration Date | 01/29/2019
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Last Update Date | 03/07/2019
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Provider Practice Location Address
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Address Line | 3975 N HUALAPAI WAY UNIT 252
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City | LAS VEGAS
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State | NV
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Zip | 89129-7937
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Country | US
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Telephone | 702-352-8888
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Fax |
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Provider Business Mailing Address
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Address Line | 9525 KICKAPOO AVE
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City | LAS VEGAS
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State | NV
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Zip | 89149-2398
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Country | US
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Telephone | 702-352-8888
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BROOKLYN R CRUZ
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Credential |
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Telephone | 702-352-8888
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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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