MEDICARE: VILLAS OF LAS VEGAS 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	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1245704626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAS OF LAS VEGAS LLC

Provider Business Mailing Address
First Line	:	2116 JADELEAF CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-6083
Country	:	US
Telephone Number	:	718-791-4705
Fax Number	:

Provider Business Practice Location Address
First Line	:	9230 CORBETT ST # 101
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-2337
Country	:	US
Telephone Number	:	718-791-4705
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MICHELE GOLDMAN
Credential	:
Telephone Number	:	718-791-4705

Provider Enumeration Date	:	01/18/2019
Last Update Date	:	06/15/2020

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