=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508301730
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HINA'S ODYSSEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2016
-----------------------------------------------------
Last Update Date | 12/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4132 S RAINBOW BLVD SUITE 149
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89103-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-475-4754
-----------------------------------------------------
Fax | 775-403-1795
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4132 S RAINBOW BLVD SUITE 149
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89103-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-475-4754
-----------------------------------------------------
Fax | 775-403-1795
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MELANIE BISON
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 775-475-4754
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | NV20141711940
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------