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General NPI Number Information
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NPI Number | 1932696499
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Entity Type | Organization
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Legal Business Name | GOOD MEDICINE RANCH LLC
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Dates
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Enumeration Date | 04/19/2018
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Last Update Date | 04/19/2018
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Provider Practice Location Address
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Address Line | 2400 N TENAYA WAY
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City | LAS VEGAS
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State | NV
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Zip | 89128-0420
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Country | US
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Telephone | 702-626-9400
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Fax |
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Provider Business Mailing Address
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Address Line | 4716 ANCHORAGE ST
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City | LAS VEGAS
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State | NV
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Zip | 89147-5101
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Country | US
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Telephone | 702-626-9400
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | HOLLY A DAVIS
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Credential | CPCI
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Telephone | 702-626-9400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | C10154
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License Number State | NV
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