Provider Demographics
NPI:1740497106
Name:MELANCON, STEPHAN
Entity type:Individual
Prefix:
First Name:STEPHAN
Middle Name:
Last Name:MELANCON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-1546
Mailing Address - Country:US
Mailing Address - Phone:702-672-1425
Mailing Address - Fax:
Practice Address - Street 1:4000 E CHARLESTON BLVD
Practice Address - Street 2:SUITE B-230
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6659
Practice Address - Country:US
Practice Address - Phone:702-968-5000
Practice Address - Fax:702-968-5050
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness