Provider Demographics
NPI:1215602073
Name:TLC COSTA BRAVA RD
Entity Type:Organization
Organization Name:TLC COSTA BRAVA RD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DORA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTIN
Authorized Official - Suffix:
Authorized Official - Credentials:RFA
Authorized Official - Phone:702-608-7238
Mailing Address - Street 1:6737 COSTA BRAVA RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-6573
Mailing Address - Country:US
Mailing Address - Phone:702-228-1770
Mailing Address - Fax:702-889-6606
Practice Address - Street 1:6737 COSTA BRAVA RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-6573
Practice Address - Country:US
Practice Address - Phone:702-228-1770
Practice Address - Fax:702-889-6606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-13
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home