Provider Demographics
NPI:1114159787
Name:MAPLE STAR NEVADA
Entity Type:Organization
Organization Name:MAPLE STAR NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:TRIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:702-733-8098
Mailing Address - Street 1:2090 SEATTLE SHORE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-5227
Mailing Address - Country:US
Mailing Address - Phone:678-361-1979
Mailing Address - Fax:
Practice Address - Street 1:2090 SEATTLE SHORE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115-5227
Practice Address - Country:US
Practice Address - Phone:678-361-1979
Practice Address - Fax:702-431-3512
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health