Provider Demographics
NPI:1477792661
Name:STATE OF NEVADA
Entity Type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:WINNEMUCCA MENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:SIRI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMILLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-687-7573
Mailing Address - Street 1:4126 TECHNOLOGY WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-2066
Mailing Address - Country:US
Mailing Address - Phone:775-687-7573
Mailing Address - Fax:775-687-7544
Practice Address - Street 1:3140 TRADERS WAY
Practice Address - Street 2:
Practice Address - City:WINNEMUCCA
Practice Address - State:NV
Practice Address - Zip Code:89445-3677
Practice Address - Country:US
Practice Address - Phone:775-623-6580
Practice Address - Fax:775-623-6584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-11
Last Update Date:2009-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV005407001Medicaid