Healthcare Provider Details

I. General information

NPI: 1255636395
Provider Name (Legal Business Name): WEST LAS VEGAS SCHOOLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2011
Last Update Date: 01/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

179 BRIDGE ST
LAS VEGAS NM
87701-3495
US

IV. Provider business mailing address

179 BRIDGE ST
LAS VEGAS NM
87701-3495
US

V. Phone/Fax

Practice location:
  • Phone: 505-426-2554
  • Fax: 505-426-2782
Mailing address:
  • Phone: 505-426-2554
  • Fax: 505-426-2782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number271289
License Number StateNM

VIII. Authorized Official

Name: MS. KARLA K GRIEGO
Title or Position: MEDICAID COORDINATOR
Credential:
Phone: 505-426-2554