MEDICARE: LEVADA HOUSE 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	NV20151522395	NV

General Provider Information

NPI Number	:	1215305818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LEVADA HOUSE LLC

Provider Business Mailing Address
First Line	:	550 N MCCARRAN BLVD
Second Line	:	BOX 204
City	:	SPARKS
State	:	NV
Zip	:	89431-5278
Country	:	US
Telephone Number	:	775-357-2623
Fax Number	:

Provider Business Practice Location Address
First Line	:	3905 CLEAR ACRE LN APT 27
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89512-1283
Country	:	US
Telephone Number	:	775-357-2623
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	ARIELL OLIVIA DIX
Credential	:
Telephone Number	:	775-357-2623

Provider Enumeration Date	:	09/13/2015
Last Update Date	:	09/13/2015

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Directions to “LEVADA HOUSE LLC ” Practice Location

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