Provider Demographics
NPI:1134580459
Name:COMPLETE CARE GROUP HOME
Entity type:Organization
Organization Name:COMPLETE CARE GROUP HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CADAVAL
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:702-449-0122
Mailing Address - Street 1:1680 SOMBRERO DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89169-2564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2437 HIGH VISTA CIR
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-3707
Practice Address - Country:US
Practice Address - Phone:702-449-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1518118850Medicaid