MEDICARE: PACIFICA SAGEBRUSH 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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1104425933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PACIFICA SAGEBRUSH LLC

Provider Business Mailing Address
First Line	:	8374 W CAPOVILLA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-3305
Country	:	US
Telephone Number	:	702-222-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	8374 W CAPOVILLA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89113-3305
Country	:	US
Telephone Number	:	702-222-3600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEEPAK ISRANI
Credential	:
Telephone Number	:	619-296-9000

Provider Enumeration Date	:	10/22/2020
Last Update Date	:	10/22/2020

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Directions to “PACIFICA SAGEBRUSH LLC ” Practice Location

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