| Radical Elevation | |
|
3551 E Bonanza Rd Ste 101 Las Vegas NV 89110-2198 | |
| (702) 482-7441 | |
| Not Available |
| Full Name | Radical Elevation |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 3551 E Bonanza Rd Ste 101, Las Vegas, Nevada |
| Authorized Official Name and Position | Brian Harge (OWNER) |
| Authorized Official Contact | 7024232703 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Radical Elevation 3551 E Bonanza Rd Ste 101 Las Vegas NV 89110-2198 Ph: (702) 482-7441 | Radical Elevation 3551 E Bonanza Rd Ste 101 Las Vegas NV 89110-2198 Ph: (702) 482-7441 |
| NPI Number | 1164097556 |
|---|---|
| Provider Enumeration Date | 05/26/2021 |
| Last Update Date | 09/23/2024 |
| Certification Date | 09/23/2024 |
| Medicare PECOS PAC ID | 0547709289 |
|---|---|
| Medicare Enrollment ID | O20240827000947 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164097556 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Miguel Angel Corzo |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1417200767 PECOS PAC ID: 0648701870 Enrollment ID: I20241001000733 |
| Provider Name | Debra Jean Moore |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1497064935 PECOS PAC ID: 6406388800 Enrollment ID: I20241010000060 |
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