Healthcare Provider Details

I. General information

NPI: 1386212900
Provider Name (Legal Business Name): PEOPLES CHURCH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2021
Last Update Date: 06/11/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 S JONES BLVD
LAS VEGAS NV
89107-2623
US

IV. Provider business mailing address

304 S JONES BLVD
LAS VEGAS NV
89107-2623
US

V. Phone/Fax

Practice location:
  • Phone: 413-687-0507
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CHANDRA PLATZ
Title or Position: OWNER
Credential:
Phone: 413-687-0507