1699158600 NPI number — FUNDAMENTAL BEHAVIORAL SERVICES LLC

Table of content: (NPI 1699158600)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699158600 NPI number — FUNDAMENTAL BEHAVIORAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FUNDAMENTAL BEHAVIORAL SERVICES 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:
1699158600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2921 N. TENAYA WAY
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:
89128-0454
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-683-2591
Provider Business Mailing Address Fax Number:
702-645-2874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3035 S. MARYLAND PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-978-8100
Provider Business Practice Location Address Fax Number:
702-857-8801
Provider Enumeration Date:
07/08/2015

Additional Information

Authorized Official

Authorized Official Last Name:
GROSSA
Authorized Official First Name:
ABBY
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
702-338-8373

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)





Copyright © 2007-2025 www.npivalidator.com