Healthcare Provider Details

I. General information

NPI: 1952674806
Provider Name (Legal Business Name): KEKOA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2012
Last Update Date: 02/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7345 FALCON ROCK DR
LAS VEGAS NV
89123-1470
US

IV. Provider business mailing address

7345 FALCON ROCK DR
LAS VEGAS NV
89123-1470
US

V. Phone/Fax

Practice location:
  • Phone: 702-513-8321
  • Fax:
Mailing address:
  • Phone: 702-513-8321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHANA WICKERSHAM
Title or Position: OWNER
Credential:
Phone: 702-513-8321