Basic Information
| Provider Information | |||||||||
| NPI: | 1649688490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTCARE NEVADA INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CTC LV | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1711 WHITNEY MESA DR | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890142080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023852090 | ||||||||
| FaxNumber: | 7029242575 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 N MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891013130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023853330 | ||||||||
| FaxNumber: | 7022077119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2014 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| AuthorizedOfficialLastName: | MAGRDICHIAN | ||||||||
| AuthorizedOfficialFirstName: | LEO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7023852090 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1699169920 | 01 | NV | PT82 | OTHER |