Basic Information
Provider Information | |||||||||
NPI: | 1144638180 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTCARE NEVADA INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CIC LV | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1711 WHITNEY MESA DR | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | NV | ||||||||
PostalCode: | 890142080 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023852090 | ||||||||
FaxNumber: | 7029242575 | ||||||||
Practice Location | |||||||||
Address1: | 401 S MARTIN LUTHER KING BLVD | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891064313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7023853330 | ||||||||
FaxNumber: | 7023855519 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/22/2014 | ||||||||
LastUpdateDate: | 07/24/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KINARD | ||||||||
AuthorizedOfficialFirstName: | ERIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | AREA DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7023852090 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | NCC,LCADC | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 100508912 | 05 | NV |   | MEDICAID | 1851574305 | 01 | NV | PT17 NPI | OTHER | 100511279 | 05 | NV |   | MEDICAID |