=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841006202
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMBRY RIDGE SENIOR CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5313 PADUA WAY
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89107-0404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-258-1669
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6549 OCTAVE AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89139-6746
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-230-2675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ERIKA VERGARA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-230-2675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------