Provider Demographics
NPI:1073006706
Name:WICKER BASKET LLC
Entity Type:Organization
Organization Name:WICKER BASKET LLC
Other - Org Name:WICKER BASKET
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNWE
Authorized Official - Prefix:
Authorized Official - First Name:LOURDES
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGUINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-445-0088
Mailing Address - Street 1:3020 BEAUFORT CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-0478
Mailing Address - Country:US
Mailing Address - Phone:702-445-0088
Mailing Address - Fax:702-476-8933
Practice Address - Street 1:3020 BEAUFORT CT
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-0478
Practice Address - Country:US
Practice Address - Phone:702-994-0857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-07
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)