Provider Demographics
NPI:1407273360
Name:P.R.I.D.E. SERVICES L.L.C.
Entity Type:Organization
Organization Name:P.R.I.D.E. SERVICES L.L.C.
Other - Org Name:LIFE CHANGERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:WALKER-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-268-8109
Mailing Address - Street 1:1516 E TROPICANA AVE STE 154
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89119-8316
Mailing Address - Country:US
Mailing Address - Phone:702-268-8109
Mailing Address - Fax:702-268-8009
Practice Address - Street 1:1516 E TROPICANA AVE STE 154
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-8316
Practice Address - Country:US
Practice Address - Phone:702-268-8109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-27
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20141081108103TB0200X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1407273360Medicaid