Provider Demographics
NPI:1164097556
Name:RADICAL ELEVATION
Entity Type:Organization
Organization Name:RADICAL ELEVATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARGE
Authorized Official - Suffix:
Authorized Official - Credentials:CVA
Authorized Official - Phone:702-423-2703
Mailing Address - Street 1:3551 E BONANZA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89110-2198
Mailing Address - Country:US
Mailing Address - Phone:702-482-7441
Mailing Address - Fax:
Practice Address - Street 1:3551 E BONANZA RD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-2198
Practice Address - Country:US
Practice Address - Phone:702-482-7441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-26
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health