MEDICARE: DOROTHY COVERSON FOUNDATION

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	:	1386113280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOROTHY COVERSON FOUNDATION

Provider Business Mailing Address
First Line	:	3075 E FLAMINGO RD STE 118
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4300
Country	:	US
Telephone Number	:	702-522-7363
Fax Number	:	702-920-8322

Provider Business Practice Location Address
First Line	:	3075 E FLAMINGO RD STE 118
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-4300
Country	:	US
Telephone Number	:	702-522-7363
Fax Number	:	702-920-8322

Authorized Official
Title or Position	:	CEO
Name	:	MR. CARLOS RAMON POLLARD
Credential	:
Telephone Number	:	702-324-2126

Provider Enumeration Date	:	11/20/2018
Last Update Date	:	11/20/2018

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