MEDICARE: COMMUNITY CONNECT, INC.

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1417394347
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CONNECT, INC.

Provider Business Mailing Address
First Line	:	5070 VEGAS VALLEY DR
Second Line	:	# 6201703
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2556
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5070 VEGAS VALLEY DR
Second Line	:	# 6201703
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-2556
Country	:	US
Telephone Number	:	702-290-7086
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	MICHAEL DEON THROWER
Credential	:
Telephone Number	:	702-290-7086

Provider Enumeration Date	:	06/01/2013
Last Update Date	:	06/01/2013

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