Provider Demographics
NPI:1386163756
Name:LIFE BREAKTHROUGH
Entity type:Organization
Organization Name:LIFE BREAKTHROUGH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KALYN
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:702-895-1883
Mailing Address - Street 1:11740 VILLA MALAPARTE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89138-6013
Mailing Address - Country:US
Mailing Address - Phone:702-895-1883
Mailing Address - Fax:
Practice Address - Street 1:10885 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-5857
Practice Address - Country:US
Practice Address - Phone:702-895-1883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-16
Last Update Date:2017-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001086363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPRN001086OtherAPRN LICENSE