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General NPI Number Information
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NPI Number | 1689919854
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Entity Type | Organization
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Legal Business Name | LLM MAHALA CORPORATION, LLC
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Dates
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Enumeration Date | 11/29/2012
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Last Update Date | 04/11/2019
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Provider Practice Location Address
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Address Line | 3030 S JONES BLVD STE 110 STE 110
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City | LAS VEGAS
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State | NV
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Zip | 89146-6793
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Country | US
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Telephone | 702-749-6926
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Fax | 702-272-2011
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Provider Business Mailing Address
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Address Line | 3030 S JONES BLVD STE 110
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City | LAS VEGAS
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State | NV
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Zip | 89146-6793
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Country | US
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Telephone | 702-749-6926
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Fax | 702-272-2011
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Authorized Official
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Title or Position | OWNER
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Name | LO'RECE MEBANE
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Credential | LCSW
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Telephone | 702-787-9227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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