Healthcare Provider Details

I. General information

NPI: 1245596790
Provider Name (Legal Business Name): STATE OF NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 W CHARLESTON BLVD
LAS VEGAS NV
89146-1126
US

IV. Provider business mailing address

6161 W CHARLESTON BLVD
LAS VEGAS NV
89146-1126
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-0996
  • Fax: 702-486-6238
Mailing address:
  • Phone: 702-486-0996
  • Fax: 702-486-6238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. STUART GHERTNER
Title or Position: AGENCY DIRECTOR
Credential: PHD
Phone: 702-486-6238