=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699357111
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STARK MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2021
-----------------------------------------------------
Last Update Date | 10/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 526 S TONOPAH DR STE 200
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89106-4013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 725-246-1483
-----------------------------------------------------
Fax | 702-440-8430
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 840 S RANCHO DR STE 4-903
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89106-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-440-8840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | MRS. WANDA MARIE WILKINS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-755-1879
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------