=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700362191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGE OF HOPE BEHAVIORAL HEALTH LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2018
-----------------------------------------------------
Last Update Date | 07/18/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 RIVER GLIDER AVE
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89084-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-515-6507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 410 RIVER GLIDER AVE
-----------------------------------------------------
City | NORTH LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89084-1221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-515-6507
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DIMONTE EVANS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-515-6507
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | NV-20181511294
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------