MEDICARE: RAISEUP COMMUNITY DEVELOPMENT CORPORATION

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	251B00000X	Case Management Agency	5909-C	NV
2	251B00000X	Case Management Agency	01168-L	NV
3	251S00000X	Community/Behavioral Health Agency	01168-L	NV
4	251S00000X	Community/Behavioral Health Agency	5909-C	NV

General Provider Information

NPI Number	:	1255622353
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAISEUP COMMUNITY DEVELOPMENT CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 571661
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89157-1661
Country	:	US
Telephone Number	:	702-592-4814
Fax Number	:	702-631-9475

Provider Business Practice Location Address
First Line	:	5328 VISTA HERMOSA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89108-4095
Country	:	US
Telephone Number	:	702-592-4814
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR/THERAPIST
Name	:	MR. ANTHONY FITZGERALD HARRIS
Credential	:	LCSW, LADC
Telephone Number	:	702-592-4814

Provider Enumeration Date	:	04/22/2011
Last Update Date	:	04/22/2011

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