MEDICARE: INNOVATING MINDS FOUNDATION LLC

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	:	1215584230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATING MINDS FOUNDATION LLC

Provider Business Mailing Address
First Line	:	6404 STARCREST DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2714
Country	:	US
Telephone Number	:	702-358-9727
Fax Number	:	702-992-0585

Provider Business Practice Location Address
First Line	:	6404 STARCREST DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-2714
Country	:	US
Telephone Number	:	702-358-9727
Fax Number	:	702-992-0585

Authorized Official
Title or Position	:	OWNER/MANAGING EMPLOYEE
Name	:	DONNA M DAVIS
Credential	:
Telephone Number	:	312-405-4121

Provider Enumeration Date	:	08/23/2019
Last Update Date	:	04/23/2021

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