Provider Demographics
NPI:1699357111
Name:STARK MEDICINE
Entity Type:Organization
Organization Name:STARK MEDICINE
Other - Org Name:NEVADA MENTAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:MRS
Authorized Official - First Name:WANDA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WILKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-755-1879
Mailing Address - Street 1:840 S RANCHO DR STE 4-903
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-3837
Mailing Address - Country:US
Mailing Address - Phone:702-440-8840
Mailing Address - Fax:
Practice Address - Street 1:526 S TONOPAH DR STE 200
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4013
Practice Address - Country:US
Practice Address - Phone:725-246-1483
Practice Address - Fax:702-440-8430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-23
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV832602698Medicaid
NV1902149248Medicaid