Healthcare Provider Details

I. General information

NPI: 1194955096
Provider Name (Legal Business Name): KIDS TURF ACADEMY II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 07/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1380 E SILVERADO RANCH BLVD
LAS VEGAS NV
89183-5924
US

IV. Provider business mailing address

1380 E SILVERADO RANCH BLVD
LAS VEGAS NV
89183-5924
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-8877
  • Fax: 702-453-8874
Mailing address:
  • Phone: 702-453-8877
  • Fax: 702-453-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number20000108590101
License Number StateNV

VIII. Authorized Official

Name: MRS. CONNIE LINNETTE HARRIS
Title or Position: DIRECTOR
Credential:
Phone: 702-491-1265