MEDICARE: SUPPORTIVE OUTREACH SERVICES INC.

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	:	1720415672
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPPORTIVE OUTREACH SERVICES INC.

Provider Business Mailing Address
First Line	:	6117 GLENBOROUGH ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-6017
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6117 GLENBOROUGH ST
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-6017
Country	:	US
Telephone Number	:	702-807-1333
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NIESHA ALLEN
Credential	:
Telephone Number	:	702-807-1333

Provider Enumeration Date	:	10/07/2013
Last Update Date	:	10/07/2013

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