MEDICARE: INNOVATIVE COLLABORATION SUPPORT SERVICES, 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	251S00000X	Community/Behavioral Health Agency	251S00000X	NV

General Provider Information

NPI Number	:	1841507449
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE COLLABORATION SUPPORT SERVICES, LLC

Provider Business Mailing Address
First Line	:	4400 S JONES BLVD UNIT 1055
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3339
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4400 S JONES BLVD UNIT 1055
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89103-3339
Country	:	US
Telephone Number	:	702-476-9405
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MR. MICHAEL DONNELL BRIDGES
Credential	:	MA
Telephone Number	:	702-476-9405

Provider Enumeration Date	:	09/03/2010
Last Update Date	:	09/03/2010

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