Healthcare Provider Details

I. General information

NPI: 1932304920
Provider Name (Legal Business Name): STATE OF NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6171 W CHARLESTON BLVD BLDG. # 12-14
LAS VEGAS NV
89146-1126
US

IV. Provider business mailing address

6171 W CHARLESTON BLVD BLDG. # 12-14
LAS VEGAS NV
89146-1126
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-6100
  • Fax: 702-486-6057
Mailing address:
  • Phone: 702-486-6100
  • Fax: 702-486-6057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JEFF MORROW
Title or Position: ADMINISTRATIVE SERVICES OFFICER
Credential:
Phone: 702-486-6100