Provider Demographics
NPI:1891536249
Name:RESIDENTAL
Entity type:Organization
Organization Name:RESIDENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:STEFANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:661-886-3583
Mailing Address - Street 1:5833 FOX HAIR STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081
Mailing Address - Country:US
Mailing Address - Phone:661-886-3583
Mailing Address - Fax:
Practice Address - Street 1:5833 FOX HAIR STREET
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081
Practice Address - Country:US
Practice Address - Phone:661-886-3583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-31
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental