MEDICARE: CENTURY ADDICTION TREATMENT CENTER LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse
3	207QA0401X	Addiction Medicine (Family Medicine) Physician
4	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1073086179
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTURY ADDICTION TREATMENT CENTER LLC

Provider Business Mailing Address
First Line	:	1771 E FLAMINGO RD STE 111B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-0851
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1771 E FLAMINGO RD STE 111B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-0851
Country	:	US
Telephone Number	:	725-777-3440
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSE ROBERT GATICALES
Credential	:	APN
Telephone Number	:	702-292-4657

Provider Enumeration Date	:	01/10/2019
Last Update Date	:	01/10/2019

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