MEDICARE: HINA'S ODYSSEY, 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	251S00000X	Community/Behavioral Health Agency	NV20141711940	NV

General Provider Information

NPI Number	:	1508301730
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HINA'S ODYSSEY, LLC

Provider Business Mailing Address
First Line	:	4132 S RAINBOW BLVD
Second Line	:	SUITE 149
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3106
Country	:	US
Telephone Number	:	775-475-4754
Fax Number	:	775-403-1795

Provider Business Practice Location Address
First Line	:	4132 S RAINBOW BLVD
Second Line	:	SUITE 149
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3106
Country	:	US
Telephone Number	:	775-475-4754
Fax Number	:	775-403-1795

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MELANIE BISON
Credential	:	PHD
Telephone Number	:	775-475-4754

Provider Enumeration Date	:	12/25/2016
Last Update Date	:	12/25/2016

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