MEDICARE: FORT PEACE

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	:	1285024968
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT PEACE

Provider Business Mailing Address
First Line	:	7121 W CRAIG RD STE 113
Second Line	:	UNIT 148
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6023
Country	:	US
Telephone Number	:	702-546-9431
Fax Number	:

Provider Business Practice Location Address
First Line	:	7121 W CRAIG RD STE 113
Second Line	:	UNIT 148
City	:	LAS VEGAS
State	:	NV
Zip	:	89129-6023
Country	:	US
Telephone Number	:	702-546-9431
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	WILLIE J FRINK III
Credential	:	BISHOP
Telephone Number	:	702-546-9431

Provider Enumeration Date	:	02/02/2015
Last Update Date	:	02/02/2015

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Directions to “FORT PEACE ” Practice Location

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