MEDICARE: CGL GROUP CORP

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	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1902175144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CGL GROUP CORP

Provider Business Mailing Address
First Line	:	1900 ELIMINATOR DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1136
Country	:	US
Telephone Number	:	702-823-3553
Fax Number	:	702-823-3553

Provider Business Practice Location Address
First Line	:	1900 ELIMINATOR DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89146-1136
Country	:	US
Telephone Number	:	702-823-3553
Fax Number	:	702-823-3553

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHRISTIAN CASTANEDA
Credential	:
Telephone Number	:	917-496-8000

Provider Enumeration Date	:	12/16/2011
Last Update Date	:	12/16/2011

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