MEDICARE: EVENING STAR ASSISTED LIVING 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	253Z00000X	In Home Supportive Care Agency	7849PCS-0	NV

General Provider Information

NPI Number	:	1871907386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVENING STAR ASSISTED LIVING LLC

Provider Business Mailing Address
First Line	:	993 COLDWATER FALLS WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-4803
Country	:	US
Telephone Number	:	702-981-9831
Fax Number	:

Provider Business Practice Location Address
First Line	:	993 COLDWATER FALLS WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-4803
Country	:	US
Telephone Number	:	702-981-9831
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	HOLLY ERIN HOFFMAN
Credential	:
Telephone Number	:	702-891-9831

Provider Enumeration Date	:	06/12/2014
Last Update Date	:	06/12/2014

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