MEDICARE: MAPLE STAR NEVADA

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1740575794
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE STAR NEVADA

Provider Business Mailing Address
First Line	:	1050 E FLAMINGO RD
Second Line	:	STE S-107
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7427
Country	:	US
Telephone Number	:	702-733-8098
Fax Number	:	702-395-6457

Provider Business Practice Location Address
First Line	:	1050 E FLAMINGO RD
Second Line	:	STE S-107
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-7427
Country	:	US
Telephone Number	:	702-733-8098
Fax Number	:	702-395-6457

Authorized Official
Title or Position	:	REGIONAL DIRECTOR
Name	:	ROBERT COWAN
Credential	:	MPA, LSW
Telephone Number	:	702-733-8098

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	02/12/2013

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