MEDICARE: MOBILE MENTAL HEALTH

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	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1659677870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE MENTAL HEALTH

Provider Business Mailing Address
First Line	:	736 HILL SHINE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2394
Country	:	US
Telephone Number	:	702-462-3604
Fax Number	:

Provider Business Practice Location Address
First Line	:	736 HILL SHINE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89031-2394
Country	:	US
Telephone Number	:	702-462-3604
Fax Number	:

Authorized Official
Title or Position	:	INDEPENDENT CONTRACTOR
Name	:	ILLYAS MALIK JENKINS
Credential	:	BS,QMHA
Telephone Number	:	702-462-3604

Provider Enumeration Date	:	02/05/2011
Last Update Date	:	02/05/2011

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Directions to “MOBILE MENTAL HEALTH ” Practice Location

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