Provider Demographics
NPI:1720372808
Name:FOUNDATION FOR POSITIVELY KIDS
Entity Type:Organization
Organization Name:FOUNDATION FOR POSITIVELY KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT MEDICAL CLINICS
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-455-5639
Mailing Address - Street 1:2480 E TOMPKINS AVE STE 222
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89121-7625
Mailing Address - Country:US
Mailing Address - Phone:702-262-0037
Mailing Address - Fax:702-262-0252
Practice Address - Street 1:2480 E TOMPKINS AVE STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89121-5466
Practice Address - Country:US
Practice Address - Phone:702-262-0037
Practice Address - Fax:702-262-0252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-06
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV1172252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100523923Medicaid