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General NPI Number Information
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NPI Number | 1780903872
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Entity Type | Organization
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Legal Business Name | HEALTHY LIFESTYLE RESIDENCE, LLC
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Dates
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Enumeration Date | 05/27/2010
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Last Update Date | 05/27/2010
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Provider Practice Location Address
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Address Line | 3990 LAKESIDE DR
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City | RENO
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State | NV
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Zip | 89509-5336
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Country | US
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Telephone | 775-828-5151
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Fax | 775-828-5152
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Provider Business Mailing Address
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Address Line | 3990 LAKESIDE DR
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City | RENO
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State | NV
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Zip | 89509-5336
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Country | US
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Telephone | 775-828-5151
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Fax | 775-828-5152
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MS. FELICISIMA A. GRAHAM
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Credential | RFA
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Telephone | 775-828-5151
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 5880AGC-0
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License Number State | NV
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