MEDICARE: INNOVATION BEHAVIORAL HEALTH SOLUTIONS, 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	273Y00000X	Rehabilitation Hospital Unit

General Provider Information

NPI Number	:	1750678199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATION BEHAVIORAL HEALTH SOLUTIONS, LLC

Provider Business Mailing Address
First Line	:	1876 VERDE MIRADA DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-3844
Country	:	US
Telephone Number	:	702-541-3563
Fax Number	:

Provider Business Practice Location Address
First Line	:	2340 PASEO DEL PRADO STE D305
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-4342
Country	:	US
Telephone Number	:	866-604-6812
Fax Number	:

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MRS. SANDRA GRAY
Credential	:	B.A.; M.S. STUDENT
Telephone Number	:	702-541-3563

Provider Enumeration Date	:	07/06/2011
Last Update Date	:	07/06/2011

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