MEDICARE: NEW AGE BEHAVIORAL HEALTH

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		NV

General Provider Information

NPI Number	:	1417388877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW AGE BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	6504 FOLKSTONE AVE
Second Line	:	UNIT 102
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-7023
Country	:	US
Telephone Number	:	678-361-1979
Fax Number	:

Provider Business Practice Location Address
First Line	:	6767 W CHARLESTON BLVD
Second Line	:	SUITE 150
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-9073
Country	:	US
Telephone Number	:	678-361-1979
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CHARLES RICHARD TRIMBLE
Credential	:	M.S.
Telephone Number	:	678-361-1979

Provider Enumeration Date	:	12/10/2013
Last Update Date	:	06/02/2015

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