Healthcare Provider Details

I. General information

NPI: 1902500028
Provider Name (Legal Business Name): BLUE 42 INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 06/23/2024
Certification Date: 06/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 W OWENS AVE STE 1
LAS VEGAS NV
89106-2451
US

IV. Provider business mailing address

8046 PAVAROTTI AVE
LAS VEGAS NV
89178-8264
US

V. Phone/Fax

Practice location:
  • Phone: 775-538-5104
  • Fax:
Mailing address:
  • Phone: 775-538-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QB0400X
TaxonomyBirthing Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JSHAUNTAE MARSHALL
Title or Position: DIRECTOR
Credential:
Phone: 775-538-5104