MEDICARE: WICKER BASKET LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311500000X	Alzheimer Center (Dementia Center)

General Provider Information

NPI Number	:	1073006706
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICKER BASKET LLC

Provider Business Mailing Address
First Line	:	3020 BEAUFORT CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-0478
Country	:	US
Telephone Number	:	702-445-0088
Fax Number	:	702-476-8933

Provider Business Practice Location Address
First Line	:	3020 BEAUFORT CT
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-0478
Country	:	US
Telephone Number	:	702-994-0857
Fax Number	:

Authorized Official
Title or Position	:	OWNWE
Name	:	LOURDES MANGUINO
Credential	:
Telephone Number	:	702-445-0088

Provider Enumeration Date	:	06/07/2018
Last Update Date	:	10/15/2020

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Directions to “WICKER BASKET LLC ” Practice Location

Language	Start Address	Practice Location

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