MEDICARE: KID'S FORT DEVELOPMENTAL CENTER 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	261QD1600X	Developmental Disabilities Clinic/Center

General Provider Information

NPI Number	:	1407609951
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KID'S FORT DEVELOPMENTAL CENTER LLC

Provider Business Mailing Address
First Line	:	3757 SCAFATI AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1908
Country	:	US
Telephone Number	:	907-744-6981
Fax Number	:

Provider Business Practice Location Address
First Line	:	3757 SCAFATI AVE
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89044-1908
Country	:	US
Telephone Number	:	907-744-6981
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	RALPH DIMAANO
Credential	:
Telephone Number	:	907-744-6981

Provider Enumeration Date	:	04/05/2024
Last Update Date	:	04/05/2024

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