MEDICARE: CYCLES OF CHANGE RECOVERY SERVICES, 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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	NV20171772492	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NV20171772492	OTHER	NV	NEVADA DIVISION OF PUBLIC AND BEHAVIORAL HEALTH SUBSTANCE ABUSE PREVENTION

General Provider Information

NPI Number	:	1689170862
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CYCLES OF CHANGE RECOVERY SERVICES, LLC

Provider Business Mailing Address
First Line	:	6069 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5579
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6069 S FORT APACHE RD STE 130
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89148-5579
Country	:	US
Telephone Number	:	702-749-5913
Fax Number	:

Authorized Official
Title or Position	:	OPERATION MANAGER
Name	:	JOSEPH HUNTER
Credential	:
Telephone Number	:	818-497-8177

Provider Enumeration Date	:	04/05/2018
Last Update Date	:	06/16/2018

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