Provider Demographics
NPI:1467603878
Name:COMMUNITY CARE HEALTH PLAN OF NEVADA, INC.
Entity Type:Organization
Organization Name:COMMUNITY CARE HEALTH PLAN OF NEVADA, INC.
Other - Org Name:AMERIGROUP NEVADA, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BOGARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-545-9842
Mailing Address - Street 1:9133 WEST RUSSELL ROAD
Mailing Address - Street 2:BUILDING 9
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-8351
Mailing Address - Country:US
Mailing Address - Phone:702-545-9842
Mailing Address - Fax:702-360-0755
Practice Address - Street 1:9133 WEST RUSSELL ROAD
Practice Address - Street 2:BUILDING 9
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-8351
Practice Address - Country:US
Practice Address - Phone:702-545-9842
Practice Address - Fax:702-360-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV17690302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100515750OtherMEDICAID - NORTH
NV100515749OtherMEDICAID - SOUTH
NV17690Medicaid