MEDICARE: DUNGARVIN NEVADA, LLC - LAS VEGAS

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	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care		NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962864439
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUNGARVIN NEVADA, LLC - LAS VEGAS

Provider Business Mailing Address
First Line	:	1444 NORTHLAND DR STE 200
Second Line	:
City	:	MENDOTA HEIGHTS
State	:	MN
Zip	:	55120-1032
Country	:	US
Telephone Number	:	651-699-0206
Fax Number	:	651-699-0799

Provider Business Practice Location Address
First Line	:	3325 W CRAIG RD STE A
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-5002
Country	:	US
Telephone Number	:	702-222-2243
Fax Number	:	702-222-0174

Authorized Official
Title or Position	:	CEO
Name	:	LORI KRESS
Credential	:
Telephone Number	:	651-699-0206

Provider Enumeration Date	:	03/24/2016
Last Update Date	:	04/27/2023

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