Basic Information
| Provider Information | |||||||||
| NPI: | 1740497106 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MELANCON | ||||||||
| FirstName: | STEPHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1255 S 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026721425 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4000 E CHARLESTON BLVD | ||||||||
| Address2: | SUITE B-230 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891046659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029685000 | ||||||||
| FaxNumber: | 7029685050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.