1164148565 NPI number — MODERN PSYCHIATRY PLLC

Table of content: (NPI 1164148565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164148565 NPI number — MODERN PSYCHIATRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MODERN PSYCHIATRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164148565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8665 W FLAMINGO RD STE 118
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89147-8624
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-318-7920
Provider Business Mailing Address Fax Number:
702-745-0531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10014 PIPESTONE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89141-8668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-318-7920
Provider Business Practice Location Address Fax Number:
702-745-0531
Provider Enumeration Date:
10/17/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WANJOHI
Authorized Official First Name:
BENSON
Authorized Official Middle Name:
WACHIRA
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
785-408-9274

Provider Taxonomy Codes

  • Taxonomy code: 2084P0802X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)