Provider Demographics
NPI:1225675861
Name:SHORELINES
Entity Type:Organization
Organization Name:SHORELINES
Other - Org Name:SHORELINES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEREDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AGOSTINO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:843-619-3571
Mailing Address - Street 1:500 N RAINBOW BLVD STE 300-345
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1082
Mailing Address - Country:US
Mailing Address - Phone:833-246-8353
Mailing Address - Fax:
Practice Address - Street 1:500 N RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89107-1082
Practice Address - Country:US
Practice Address - Phone:843-619-3571
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1871752303Medicaid
NV816203OtherNV - APRN LICENSE