Provider Demographics
NPI:1497501019
Name:SKYSHROUD HOME HEALTH CORP
Entity type:Organization
Organization Name:SKYSHROUD HOME HEALTH CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAINT DON NIEL
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:REYES
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATP
Authorized Official - Phone:702-289-9797
Mailing Address - Street 1:5480 COLD LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7609
Mailing Address - Country:US
Mailing Address - Phone:702-289-9797
Mailing Address - Fax:
Practice Address - Street 1:5480 COLD LAKE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-7609
Practice Address - Country:US
Practice Address - Phone:702-289-9797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1750957148Medicaid
NV1447850318Medicaid
NV1457804239Medicaid