1598015240 NPI number — NUEVA VIDA MENTAL HEALTH LLC

Table of content: (NPI 1598015240)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598015240 NPI number — NUEVA VIDA MENTAL HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NUEVA VIDA MENTAL HEALTH 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:
6
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:
1598015240
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4170 S DECATUR BLVD STE C1
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:
89103-5863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-659-8827
Provider Business Mailing Address Fax Number:
702-852-0984

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4170 S DECATUR BLVD STE C1
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:
89103-5863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-659-8827
Provider Business Practice Location Address Fax Number:
702-852-0984
Provider Enumeration Date:
09/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
REZANOV
Authorized Official First Name:
MARYSOL
Authorized Official Middle Name:
Authorized Official Title or Position:
MENTAL HEALTH THERAPIST
Authorized Official Telephone Number:
702-659-8827

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6215-C , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1982056172 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1891867107 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003116146 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1316606874 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1497120059 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1003127499 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NV ) . This identifiers is of the category "OTHER".
  • Identifier: 1225338361 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1407281561 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com