Provider Demographics
NPI:1366477036
Name:NEVADA FAMILY PRACTICE RESIDENCY PROGRAM, INC.
Entity Type:Organization
Organization Name:NEVADA FAMILY PRACTICE RESIDENCY PROGRAM, INC.
Other - Org Name:MOJAVE MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:R
Authorized Official - Last Name:PARCELLS
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:702-968-5059
Mailing Address - Street 1:4000 E CHARLESTON BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-6659
Mailing Address - Country:US
Mailing Address - Phone:702-968-5059
Mailing Address - Fax:
Practice Address - Street 1:4000 E CHARLESTON BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-6659
Practice Address - Country:US
Practice Address - Phone:702-968-5059
Practice Address - Fax:702-968-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100507624Medicaid
NV100507627Medicaid
NV100507629Medicaid
NV100508688Medicaid
NV100508689Medicaid
NV100507625Medicaid
NV100507626Medicaid
NV100507628Medicaid
NV100508048Medicaid
NV100508048Medicaid