MEDICARE: TLC COSTA BRAVA RD

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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1215602073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TLC COSTA BRAVA RD

Provider Business Mailing Address
First Line	:	6737 COSTA BRAVA RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6573
Country	:	US
Telephone Number	:	702-228-1770
Fax Number	:	702-889-6606

Provider Business Practice Location Address
First Line	:	6737 COSTA BRAVA RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-6573
Country	:	US
Telephone Number	:	702-228-1770
Fax Number	:	702-889-6606

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MS. DORA VALENTIN
Credential	:	RFA
Telephone Number	:	702-608-7238

Provider Enumeration Date	:	08/13/2021
Last Update Date	:	08/13/2021

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