MEDICARE: ROYAL OUTREACH BEHAVIORAL REHABILITATION CENTER 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	251S00000X	Community/Behavioral Health Agency	NV20181251049	NV

General Provider Information

NPI Number	:	1942790712
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROYAL OUTREACH BEHAVIORAL REHABILITATION CENTER LLC

Provider Business Mailing Address
First Line	:	2112 INTERBAY ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89128-6502
Country	:	US
Telephone Number	:	702-219-5283
Fax Number	:

Provider Business Practice Location Address
First Line	:	4640 W CHARLESTON BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89102-1503
Country	:	US
Telephone Number	:	702-219-5283
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. PRINCE IGBOAMAZU
Credential	:	PHD
Telephone Number	:	702-219-5283

Provider Enumeration Date	:	05/16/2018
Last Update Date	:	02/23/2026

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