Provider Demographics
NPI:1205504917
Name:CHARLESTON PEDIATRIC SNF LLC
Entity type:Organization
Organization Name:CHARLESTON PEDIATRIC SNF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:MATHIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-310-3720
Mailing Address - Street 1:2496 W CHARLESTON BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-2179
Mailing Address - Country:US
Mailing Address - Phone:702-310-3720
Mailing Address - Fax:702-310-3722
Practice Address - Street 1:2496 W CHARLESTON BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-2179
Practice Address - Country:US
Practice Address - Phone:702-310-3720
Practice Address - Fax:702-310-3722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility