=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881105104
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FMT BEHAVIORAL HEALTH SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2017
-----------------------------------------------------
Last Update Date | 10/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1012 BISTRO BAY AVE
-----------------------------------------------------
City | N LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89086-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-789-8038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1012 BISTRO BAY AVE
-----------------------------------------------------
City | N LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89086-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | FRANCISCA IYERE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-789-8038
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------