=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780034751
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHATEAU AMORE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2016
-----------------------------------------------------
Last Update Date | 06/21/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7830 SPENCER ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89123-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-203-3009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7830 SPENCER ST
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89123-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-203-3009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | CHRISTINA SMITH
-----------------------------------------------------
Credential | ADMINISTRATOR, MSW
-----------------------------------------------------
Telephone | 702-203-3009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | 8453-AGC-0
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------