Basic Information
| Provider Information | |||||||||
| NPI: | 1386732659 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THI OF NEVADA II AT DESERT LANE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 640 S MARTIN L KING BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891064413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023823155 | ||||||||
| FaxNumber: | 7023845659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 07/25/2019 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | DARRIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7025658555 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 5602006 | 05 | NV | MEDICAID |