Healthcare Provider Details

I. General information

NPI: 1659677870
Provider Name (Legal Business Name): MOBILE MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2011
Last Update Date: 02/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 HILL SHINE AVE
NORTH LAS VEGAS NV
89031-2394
US

IV. Provider business mailing address

736 HILL SHINE AVE
NORTH LAS VEGAS NV
89031-2394
US

V. Phone/Fax

Practice location:
  • Phone: 702-462-3604
  • Fax:
Mailing address:
  • Phone: 702-462-3604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ILLYAS MALIK JENKINS
Title or Position: INDEPENDENT CONTRACTOR
Credential: BS,QMHA
Phone: 702-462-3604