Provider Demographics
NPI:1477925329
Name:PERIWINKLE GROUP LLC
Entity Type:Organization
Organization Name:PERIWINKLE GROUP LLC
Other - Org Name:OTAC HEALTH MANAGMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JO
Authorized Official - Middle Name:
Authorized Official - Last Name:CATO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-657-6500
Mailing Address - Street 1:4270 CAMERON ST
Mailing Address - Street 2:3A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-7704
Mailing Address - Country:US
Mailing Address - Phone:702-657-6500
Mailing Address - Fax:702-664-0502
Practice Address - Street 1:4270 CAMERON ST
Practice Address - Street 2:3A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-7704
Practice Address - Country:US
Practice Address - Phone:702-657-6500
Practice Address - Fax:702-664-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
NV251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health