Healthcare Provider Details

I. General information

NPI: 1720372808
Provider Name (Legal Business Name): FOUNDATION FOR POSITIVELY KIDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 E TOMPKINS AVE STE 101
LAS VEGAS NV
89121-5466
US

IV. Provider business mailing address

2480 E TOMPKINS AVE STE 222
LAS VEGAS NV
89121-7625
US

V. Phone/Fax

Practice location:
  • Phone: 702-262-0037
  • Fax: 702-262-0252
Mailing address:
  • Phone: 702-262-0037
  • Fax: 702-262-0252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberNV1172
License Number StateNV

VIII. Authorized Official

Name: JUDY A NEW
Title or Position: VICE PRESIDENT MEDICAL CLINICS
Credential:
Phone: 702-455-5639