Healthcare Provider Details

I. General information

NPI: 1831494673
Provider Name (Legal Business Name): MOJAVE MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E CHARLESTON BLVD STE 230
LAS VEGAS NV
89104-6659
US

IV. Provider business mailing address

4000 E CHARLESTON BLVD HM # 617
LAS VEGAS NV
89104-6659
US

V. Phone/Fax

Practice location:
  • Phone: 702-555-1212
  • Fax:
Mailing address:
  • Phone: 702-555-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License NumberRN67139
License Number StateNV

VIII. Authorized Official

Name: LASHARE EDWARDS
Title or Position: RN
Credential: REGISTERED NURSE
Phone: 310-555-1212