Basic Information
| Provider Information | |||||||||
| NPI: | 1316142623 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEVADA FAMILY PRACTICE RESIDENCY PROGRAM, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MOJAVE ADULT, CHILD AND FAMILY SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 745 W MOANA LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895094932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753343033 | ||||||||
| FaxNumber: | 7753343022 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 W MOANA LN | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895094932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753343033 | ||||||||
| FaxNumber: | 7753343022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 06/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PARCELLS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7029685059 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LISW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | NV | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 005416100 | 05 | NV | MEDICAID |