Healthcare Provider Details

I. General information

NPI: 1326461047
Provider Name (Legal Business Name): MOUNTAIN INTERVAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 S JONES BLVD D3
LAS VEGAS NV
89103-3370
US

IV. Provider business mailing address

4425 S JONES BLVD D3
LAS VEGAS NV
89103-3370
US

V. Phone/Fax

Practice location:
  • Phone: 702-991-3150
  • Fax:
Mailing address:
  • Phone: 702-991-3150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. DAVID CLARK
Title or Position: SUPERVISOR
Credential:
Phone: 702-991-3150