Provider Demographics
NPI:1851825897
Name:AMBIANCE PROVIDERS HOME SERVICES
Entity Type:Organization
Organization Name:AMBIANCE PROVIDERS HOME SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSR
Authorized Official - Prefix:
Authorized Official - First Name:NAHOM
Authorized Official - Middle Name:BERHE
Authorized Official - Last Name:HAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-642-7503
Mailing Address - Street 1:4050 GARDELLA AVE
Mailing Address - Street 2:APT # 522
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89512-1028
Mailing Address - Country:US
Mailing Address - Phone:775-276-9979
Mailing Address - Fax:775-205-6731
Practice Address - Street 1:1298 HIGHGATE CT
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-0762
Practice Address - Country:US
Practice Address - Phone:775-276-9979
Practice Address - Fax:775-205-6731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20171076228320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness