MEDICARE: R AND L ADULT CARE HOME 2 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1487231163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	R AND L ADULT CARE HOME 2 LLC

Provider Business Mailing Address
First Line	:	1013 STONEYPEAK AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-3239
Country	:	US
Telephone Number	:	702-277-6724
Fax Number	:	888-291-9747

Provider Business Practice Location Address
First Line	:	1013 STONEYPEAK AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-3239
Country	:	US
Telephone Number	:	702-277-6724
Fax Number	:	888-291-9747

Authorized Official
Title or Position	:	CO-OWNER
Name	:	KELLI GRIMLIE
Credential	:	APRN
Telephone Number	:	702-756-9911

Provider Enumeration Date	:	03/27/2021
Last Update Date	:	03/27/2021

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