Provider Demographics
NPI:1609388602
Name:INFINITE WAY BEHAVIOR
Entity Type:Organization
Organization Name:INFINITE WAY BEHAVIOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:WARNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-699-0032
Mailing Address - Street 1:1113 VIA MONTICANO
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-1502
Mailing Address - Country:US
Mailing Address - Phone:904-699-0032
Mailing Address - Fax:
Practice Address - Street 1:1113 VIA MONTICANO
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-1502
Practice Address - Country:US
Practice Address - Phone:904-699-0032
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20171265805251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1639508260Medicaid