Provider Demographics
NPI:1568725935
Name:ELEVATE LIFE FAMILY SERVICES, LLC
Entity Type:Organization
Organization Name:ELEVATE LIFE FAMILY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:PEARL
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-630-5009
Mailing Address - Street 1:2605 RAINBOW GLOW ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3709
Mailing Address - Country:US
Mailing Address - Phone:702-630-5009
Mailing Address - Fax:
Practice Address - Street 1:2605 RAINBOW GLOW ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3709
Practice Address - Country:US
Practice Address - Phone:702-630-5009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1932500000XMedicaid