Healthcare Provider Details

I. General information

NPI: 1588969737
Provider Name (Legal Business Name): MYMS CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2011
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 S EASTERN AVE SUITE 253
LAS VEGAS NV
89123-8038
US

IV. Provider business mailing address

4616 W SAHARA AVE SUITE 310
LAS VEGAS NV
89102-3654
US

V. Phone/Fax

Practice location:
  • Phone: 702-860-8573
  • Fax: 702-562-8133
Mailing address:
  • Phone: 702-860-8573
  • Fax: 702-562-8133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberCI-0010
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberCI-0010
License Number StateNV
# 4
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY GIBSON
Title or Position: EXECUTIVE DIRECTOR
Credential: CPC-INTERN
Phone: 702-860-8573