=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881686855
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LB REGENCY PLAZA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6031 W CHEYENNE AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89108-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-658-5882
-----------------------------------------------------
Fax | 702-658-5842
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6031 W CHEYENNE AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89108-4200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-658-5882
-----------------------------------------------------
Fax | 702-658-5842
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | JOSEPH C TUTERA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-444-0900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 2089AGC-9
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------