MEDICARE: HEART OF GWENDOLYN

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1578028916
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEART OF GWENDOLYN

Provider Business Mailing Address
First Line	:	1881 W ALEXANDER RD UNIT 2088
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-9049
Country	:	US
Telephone Number	:	702-428-4294
Fax Number	:

Provider Business Practice Location Address
First Line	:	1881 W ALEXANDER RD UNIT 2088
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-9049
Country	:	US
Telephone Number	:	702-428-4294
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KEYLAUNIE SEALS
Credential	:
Telephone Number	:	702-428-4294

Provider Enumeration Date	:	02/08/2019
Last Update Date	:	02/08/2019

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Directions to “HEART OF GWENDOLYN ” Practice Location

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