Healthcare Provider Details

I. General information

NPI: 1942595210
Provider Name (Legal Business Name): MAPLE STAR NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8455 OFFENHAUSER DR #517
RENO NV
89511
US

IV. Provider business mailing address

8455 OFFENHAUSER DR #517
RENO NV
89511-1752
US

V. Phone/Fax

Practice location:
  • Phone: 775-852-8335
  • Fax:
Mailing address:
  • Phone: 775-852-8335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberFF-125404617
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberGF880321776-0316
License Number StateNV

VIII. Authorized Official

Name: MRS. CHERYL CHRISTINA GRIMES
Title or Position: THERAPUTIC FOSTER PARENT
Credential:
Phone: 775-852-8335