Healthcare Provider Details

I. General information

NPI: 1821457474
Provider Name (Legal Business Name): SNCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8832 QUAIL COUNTRY WAY APT 26-204
LAS VEGAS NV
89117-3478
US

IV. Provider business mailing address

8832 QUAIL COUNTRY WAY APT 26-204
LAS VEGAS NV
89117-3478
US

V. Phone/Fax

Practice location:
  • Phone: 469-340-8760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNY BELIZAIRE
Title or Position: PSR
Credential:
Phone: 469-340-8760