Healthcare Provider Details

I. General information

NPI: 1205268695
Provider Name (Legal Business Name): EXDOUS FAMILY & GUIDANCE COALITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2013
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 S MARYLAND PKWY
LAS VEGAS NV
89104-3311
US

IV. Provider business mailing address

1415 S MARYLAND PKWY
LAS VEGAS NV
89104-3311
US

V. Phone/Fax

Practice location:
  • Phone: 702-569-4455
  • Fax:
Mailing address:
  • Phone: 702-569-4455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License NumberNV20131436018
License Number StateNV

VIII. Authorized Official

Name: MYRNA PILI
Title or Position: PART OWNER
Credential:
Phone: 702-569-4455