MEDICARE: CHRISTIAN COUNSELING CENTER, 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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1285802637
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTIAN COUNSELING CENTER, LLC

Provider Business Mailing Address
First Line	:	2723 E RUSSELL RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-2426
Country	:	US
Telephone Number	:	702-248-4547
Fax Number	:	702-248-1942

Provider Business Practice Location Address
First Line	:	2723 E RUSSELL RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-2426
Country	:	US
Telephone Number	:	702-248-4547
Fax Number	:	702-248-1942

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	RANDY BLIZZARD
Credential	:
Telephone Number	:	702-248-4547

Provider Enumeration Date	:	02/19/2008
Last Update Date	:	01/05/2010

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