Provider Demographics
NPI:1457815961
Name:HOUSE OF CHAMPIONS USA LLC
Entity Type:Organization
Organization Name:HOUSE OF CHAMPIONS USA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKLYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-352-8888
Mailing Address - Street 1:9525 KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-2398
Mailing Address - Country:US
Mailing Address - Phone:702-352-8888
Mailing Address - Fax:
Practice Address - Street 1:3975 N HUALAPAI WAY UNIT 252
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89129-7937
Practice Address - Country:US
Practice Address - Phone:702-352-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-29
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health