MEDICARE: PRODUCTIVE MEMBER'S OF SOCIETY COMMUNITY AND FAMILY SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1083164693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRODUCTIVE MEMBER'S OF SOCIETY COMMUNITY AND FAMILY SERVICES

Provider Business Mailing Address
First Line	:	2121 E FLAMINGO RD STE 114
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5123
Country	:	US
Telephone Number	:	702-234-9339
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 E FLAMINGO RD STE 114
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5123
Country	:	US
Telephone Number	:	702-234-9339
Fax Number	:

Authorized Official
Title or Position	:	LEAD LIFE ENHANCEMENT CONSULTANT-I
Name	:	LACOLE S JAMES
Credential	:	MSW
Telephone Number	:	702-234-9339

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	10/06/2016

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