Healthcare Provider Details

I. General information

NPI: 1871299180
Provider Name (Legal Business Name): AUTISM PRIDE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5891 ROCKWAY GLEN AVE
LAS VEGAS NV
89141-8854
US

IV. Provider business mailing address

5891 ROCKWAY GLEN AVE
LAS VEGAS NV
89141-8854
US

V. Phone/Fax

Practice location:
  • Phone: 702-882-4975
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: LOUIE NOVELO TANDIONO-CELLONA
Title or Position: CEO
Credential: MBA
Phone: 702-882-4975