Basic Information
| Provider Information | |||||||||
| NPI: | 1770521346 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THI OF NEVADA AT HEARTHSTONE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEARTHSTONE OF NORTHERN NEVADA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS GLENCOE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
| FaxNumber: | 4107731321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 BARING BLVD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894346735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7756262224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 06/28/2011 | ||||||||
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| AuthorizedOfficialLastName: | LARSON | ||||||||
| AuthorizedOfficialFirstName: | MOLLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7756262224 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1186SNF-14 | NV | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001916850 | 05 | NV | MEDICAID |