MEDICARE: HILLSTONE THERAPEUTIC TEAM OF NEVADA

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	251S00000X	Community/Behavioral Health Agency	NV20131697710	NV

General Provider Information

NPI Number	:	1346671344
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HILLSTONE THERAPEUTIC TEAM OF NEVADA

Provider Business Mailing Address
First Line	:	2971 N GATEWAY RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-7452
Country	:	US
Telephone Number	:	702-982-8398
Fax Number	:	702-982-8398

Provider Business Practice Location Address
First Line	:	2971 N GATEWAY RD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-7452
Country	:	US
Telephone Number	:	702-982-8398
Fax Number	:	702-982-8398

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. DOMINIQUE BLAKE BASS
Credential	:	N/A
Telephone Number	:	702-300-0816

Provider Enumeration Date	:	12/02/2013
Last Update Date	:	12/02/2013

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