MEDICARE: EXCEPTIONAL MINDS

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	NV20171737643	NV

General Provider Information

NPI Number	:	1497268163
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCEPTIONAL MINDS

Provider Business Mailing Address
First Line	:	8325 JEEVES CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4947
Country	:	US
Telephone Number	:	602-592-0503
Fax Number	:

Provider Business Practice Location Address
First Line	:	8325 JEEVES CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4947
Country	:	US
Telephone Number	:	602-592-0503
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DOMINQUE INGRAM
Credential	:
Telephone Number	:	602-592-0503

Provider Enumeration Date	:	11/15/2017
Last Update Date	:	11/16/2017

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Directions to “EXCEPTIONAL MINDS ” Practice Location

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