=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851825897
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMBIANCE PROVIDERS HOME SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2017
-----------------------------------------------------
Last Update Date | 04/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1298 HIGHGATE CT
-----------------------------------------------------
City | SPARKS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89434-0762
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-276-9979
-----------------------------------------------------
Fax | 775-205-6731
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4050 GARDELLA AVE APT # 522
-----------------------------------------------------
City | RENO
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89512-1028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 775-276-9979
-----------------------------------------------------
Fax | 775-205-6731
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSR
-----------------------------------------------------
Name | NAHOM BERHE HAGOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 202-642-7503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | NV20171076228
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------