Basic Information
| Provider Information | |||||||||
| NPI: | 1548804529 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRST PERSON CARE CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 S 4TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023808118 | ||||||||
| FaxNumber: | 7023802929 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 S 4TH ST STE 111 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891041046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023808118 | ||||||||
| FaxNumber: | 7023802929 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | JACOB | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | ELLAZAR | ||||||||
| AuthorizedOfficialTitleorPosition: | COMPLIANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7023808118 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 1548629132 | 05 | NV | MEDICAID | 1710499264 | 05 | NV | MEDICAID |