Provider Demographics
NPI:1922453448
Name:DESERT STATE DAY TREATMENT CENTER LLC
Entity Type:Organization
Organization Name:DESERT STATE DAY TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:IMANI
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-556-8102
Mailing Address - Street 1:11389 OGDEN MILLS DR UNIT 103
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-3324
Mailing Address - Country:US
Mailing Address - Phone:702-556-8102
Mailing Address - Fax:
Practice Address - Street 1:6396 MCLEOD DR STE 6
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4429
Practice Address - Country:US
Practice Address - Phone:702-556-8102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20161177555251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health