Provider Demographics
NPI:1760544969
Name:NV ST DV MH DS SO NV MR SVCS
Entity Type:Organization
Organization Name:NV ST DV MH DS SO NV MR SVCS
Other - Org Name:DESERT REGIONAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMIN SERVICE OFFICER III
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:ASHCRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-687-0511
Mailing Address - Street 1:1391 S JONES BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89146-1200
Mailing Address - Country:US
Mailing Address - Phone:702-486-6200
Mailing Address - Fax:702-486-6368
Practice Address - Street 1:1391 S JONES BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1200
Practice Address - Country:US
Practice Address - Phone:702-486-6200
Practice Address - Fax:702-486-6368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV698IMR-16320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV005402091Medicaid