Provider Demographics
NPI:1790063626
Name:APPLE GROVE TREATMENT CENTER
Entity Type:Organization
Organization Name:APPLE GROVE TREATMENT CENTER
Other - Org Name:APPLE GROVE FOSTER AGENCY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDULAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-576-7942
Mailing Address - Street 1:3155 E PATRICK LN
Mailing Address - Street 2:STE 1
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-3481
Mailing Address - Country:US
Mailing Address - Phone:702-992-0576
Mailing Address - Fax:702-992-0391
Practice Address - Street 1:3155 E PATRICK LN
Practice Address - Street 2:STE 1
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3481
Practice Address - Country:US
Practice Address - Phone:702-992-0576
Practice Address - Fax:702-992-0391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-26
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency