Healthcare Provider Details

I. General information

NPI: 1245676410
Provider Name (Legal Business Name): FAMILY AND CHILD TREATMENT (FACT)
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6431 W SAHARA AVE STE 200
LAS VEGAS NV
89146-3064
US

IV. Provider business mailing address

6431 W SAHARA AVE STE 200
LAS VEGAS NV
89146-3064
US

V. Phone/Fax

Practice location:
  • Phone: 702-258-5855
  • Fax: 702-258-9767
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License NumberNV19841011323
License Number StateNV

VIII. Authorized Official

Name: SHAWNETTE ROQUE
Title or Position: SUBSTANCE ABUSE COUNSELOR
Credential:
Phone: 702-258-5855