Basic Information
| Provider Information | |||||||||
| NPI: | 1902234131 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAPLE STAR NEVADA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 E FLAMINGO RD | ||||||||
| Address2: | S-107 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891197427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027338098 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1050 E FLAMINGO RD | ||||||||
| Address2: | S-107 | ||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891197427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7027338098 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2013 | ||||||||
| LastUpdateDate: | 10/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | MOUYIOS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECT SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7027338098 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Community Health Worker |
No ID Information.