Healthcare Provider Details

I. General information

NPI: 1457492332
Provider Name (Legal Business Name): MAPLE STAR NEVADA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 W 7TH ST STE 160
RENO NV
89503-2706
US

IV. Provider business mailing address

855 W 7TH ST STE 160
RENO NV
89503-2706
US

V. Phone/Fax

Practice location:
  • Phone: 775-677-2216
  • Fax: 775-322-4460
Mailing address:
  • Phone: 775-677-2216
  • Fax: 775-322-4460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANTOINETTE POULSON
Title or Position: PROGRAM MANAGER
Credential:
Phone: 775-677-2216