Provider Demographics
NPI:1346671344
Name:HILLSTONE THERAPEUTIC TEAM OF NEVADA
Entity Type:Organization
Organization Name:HILLSTONE THERAPEUTIC TEAM OF NEVADA
Other - Org Name:HILLSTONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:BLAKE
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:N/A
Authorized Official - Phone:702-300-0816
Mailing Address - Street 1:2971 N GATEWAY RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-7452
Mailing Address - Country:US
Mailing Address - Phone:702-982-8398
Mailing Address - Fax:702-982-8398
Practice Address - Street 1:2971 N GATEWAY RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-7452
Practice Address - Country:US
Practice Address - Phone:702-982-8398
Practice Address - Fax:702-982-8398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20131697710251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health