Provider Demographics
NPI:1902444557
Name:ADULT CARE HOME LLC
Entity Type:Organization
Organization Name:ADULT CARE HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KARPAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:PANNU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-769-5951
Mailing Address - Street 1:11838 COGOLETO AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-4687
Mailing Address - Country:US
Mailing Address - Phone:702-769-5951
Mailing Address - Fax:702-818-4663
Practice Address - Street 1:10315 QUEENSBURY AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89135-2132
Practice Address - Country:US
Practice Address - Phone:702-629-4663
Practice Address - Fax:702-818-4663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2019-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005059025Medicaid