Provider Demographics
NPI:1467761239
Name:PRICE, CHARLENE M
Entity Type:Individual
Prefix:
First Name:CHARLENE
Middle Name:M
Last Name:PRICE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 MALIBU SANDS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-1328
Mailing Address - Country:US
Mailing Address - Phone:702-575-5238
Mailing Address - Fax:702-649-6374
Practice Address - Street 1:1116 MALIBU SANDS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89086-1328
Practice Address - Country:US
Practice Address - Phone:702-575-5238
Practice Address - Fax:702-649-6374
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005055270Medicaid