Basic Information
| Provider Information | |||||||||
| NPI: | 1083797484 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR BEHAVIORAL HEALTH NEVADA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 897 | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027960660 | ||||||||
| FaxNumber: | 7027961835 | ||||||||
| Practice Location | |||||||||
| Address1: | 3050 EAST DESERT ROAD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027960660 | ||||||||
| FaxNumber: | 7027961835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 05/24/2011 | ||||||||
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| AuthorizedOfficialLastName: | MASSMAN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7027960660 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2800X | 2569NTC-7 | NV | N | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic | 261QM2800X | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | Methadone Clinic |
ID Information
| ID | Type | State | Issuer | Description | 001702150 | 05 | NV | MEDICAID |