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General NPI Number Information
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NPI Number | 1801739669
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Entity Type | Organization
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Legal Business Name | WYATT HOME LLC
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Dates
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Enumeration Date | 04/14/2026
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Last Update Date | 04/14/2026
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Provider Practice Location Address
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Address Line | 1113 WYATT AVE
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City | LAS VEGAS
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State | NV
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Zip | 89106-2440
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Country | US
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Telephone | 702-888-1312
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Fax |
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Provider Business Mailing Address
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Address Line | 1113 WYATT AVE
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City | LAS VEGAS
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State | NV
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Zip | 89106-2440
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | LC DIZON
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Credential |
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Telephone | 702-569-6148
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State |
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