Provider Demographics
NPI:1316538465
Name:FUENTE DE VIDA MENTAL HEALTH SERVICES
Entity Type:Organization
Organization Name:FUENTE DE VIDA MENTAL HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PERLA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-572-6379
Mailing Address - Street 1:2545 CHANDLER AVE STE 7
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-4007
Mailing Address - Country:US
Mailing Address - Phone:702-544-1638
Mailing Address - Fax:
Practice Address - Street 1:2545 CHANDLER AVE STE 7
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-4007
Practice Address - Country:US
Practice Address - Phone:702-544-1638
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-01
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250013637Medicaid