1790322196 NPI number — FAMILY CENTERS OF NEVADA LLC

Table of content: MATTHEW GERARD O'NEIL P.T. (NPI 1508835760)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790322196 NPI number — FAMILY CENTERS OF NEVADA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY CENTERS OF NEVADA LLC
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:
1790322196
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6545 S FORT APACHE RD STE 135-133
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:
89148-6752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-277-5406
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
222 S RAINBOW BLVD STE 212
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:
89145-5356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-277-5406
Provider Business Practice Location Address Fax Number:
702-852-0607
Provider Enumeration Date:
12/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
COLE
Authorized Official First Name:
KIYONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER / CEO
Authorized Official Telephone Number:
702-277-5406

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1134463821 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1588105530 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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