=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669910394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAGE BRUSH BEHAVIROAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/01/2017
-----------------------------------------------------
Last Update Date | 02/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2780 SUNNY SLOPE DR
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89434-2679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-354-5567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2780 SUNNY SLOPE DR
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89434-2679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-354-5567
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JACQUELINE DE LA CRUZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 775-354-5567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------