Provider Demographics
NPI:1396831152
Name:STATE OF NEVADA
Entity Type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUREAU CHIEF
Authorized Official - Prefix:MS
Authorized Official - First Name:JANELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MULVENON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-684-3461
Mailing Address - Street 1:1161 S VALLEY VIEW BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1854
Mailing Address - Country:US
Mailing Address - Phone:702-486-7670
Mailing Address - Fax:
Practice Address - Street 1:1161 S VALLEY VIEW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1854
Practice Address - Country:US
Practice Address - Phone:702-486-7670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV005402024Medicaid
NV001702024Medicaid