Provider Demographics
NPI:1740580612
Name:CHILDANDFAMILYSERVICES
Entity Type:Organization
Organization Name:CHILDANDFAMILYSERVICES
Other - Org Name:ADOLUDIT TREATMENT CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:PROGRAM MANGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:775-688-1633
Mailing Address - Street 1:480GALLETTI WAY BLDG 9
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89431
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:480 GALLETTI WAY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-5564
Practice Address - Country:US
Practice Address - Phone:775-688-1633
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDERN BEHAVIORAL SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-26
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV7777777322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7777777Medicaid