MEDICARE: MOUNTAIN INTERVAL, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1023324076
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN INTERVAL, LLC

Provider Business Mailing Address
First Line	:	4425 S JONES BLVD
Second Line	:	SUITE # D3
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3370
Country	:	US
Telephone Number	:	702-991-3150
Fax Number	:	866-658-4052

Provider Business Practice Location Address
First Line	:	4425 S JONES BLVD
Second Line	:	SUITE D3
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3370
Country	:	US
Telephone Number	:	702-991-3150
Fax Number	:	866-658-4052

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	MR. DAVID CLARK
Credential	:	MA
Telephone Number	:	702-991-3150

Provider Enumeration Date	:	08/28/2010
Last Update Date	:	03/22/2017

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