Healthcare Provider Details

I. General information

NPI: 1982922696
Provider Name (Legal Business Name): WEST LAS VEGAS SCHOOL BASED HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1024 SOUTH PACIFIC
LAS VEGAS NM
87701
US

IV. Provider business mailing address

179 BRIDGE ST
LAS VEGAS NM
87701-3495
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-2564
  • Fax: 505-426-2579
Mailing address:
  • Phone: 505-426-2564
  • Fax: 505-426-2579

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number261QS1000X
License Number StateNM

VIII. Authorized Official

Name: MRS. YOLANDA CARRILLO
Title or Position: COORDINATOR
Credential:
Phone: 505-426-2564