MEDICARE: LIFE LAUNCH CENTERS 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1356818066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE LAUNCH CENTERS OF NEVADA

Provider Business Mailing Address
First Line	:	315 W HILTON DR # 3-4
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84770-2319
Country	:	US
Telephone Number	:	435-767-0552
Fax Number	:	435-767-0278

Provider Business Practice Location Address
First Line	:	3037 E WARM SPRINGS RD STE 400
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-3759
Country	:	US
Telephone Number	:	833-803-3883
Fax Number	:

Authorized Official
Title or Position	:	OWNER/FINANCIAL
Name	:	JONI DYCHES
Credential	:	IOP MENTAL HEALTH
Telephone Number	:	435-767-0552

Provider Enumeration Date	:	10/31/2018
Last Update Date	:	09/03/2019

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