Provider Demographics
NPI:1073188629
Name:NIRVANA SQUARED LLC
Entity Type:Organization
Organization Name:NIRVANA SQUARED LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:PLUMMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-366-5675
Mailing Address - Street 1:7426 E STETSON DR UNIT 3017E
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-3877
Mailing Address - Country:US
Mailing Address - Phone:301-366-5675
Mailing Address - Fax:
Practice Address - Street 1:1027 E SELDON LN
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3259
Practice Address - Country:US
Practice Address - Phone:301-366-5675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities