Healthcare Provider Details

I. General information

NPI: 1881755635
Provider Name (Legal Business Name): NV ST DV MH DS DESERT DEV CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1391 S JONES BLVD
LAS VEGAS NV
89146-1200
US

IV. Provider business mailing address

1391 S JONES BLVD
LAS VEGAS NV
89146-1200
US

V. Phone/Fax

Practice location:
  • Phone: 702-486-6200
  • Fax: 702-486-6368
Mailing address:
  • Phone: 702-486-6200
  • Fax: 702-486-6368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number698IMR-16
License Number StateNV

VIII. Authorized Official

Name: MICHELLE L. ASHCRAFT
Title or Position: ADMINISTRATIVE SERVICES OFFICER III
Credential:
Phone: 775-687-0511