Provider Demographics
NPI:1891052627
Name:A.C.T.I.V.E
Entity Type:Organization
Organization Name:A.C.T.I.V.E
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:MUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-281-6560
Mailing Address - Street 1:52 PROMINENT BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89002-3306
Mailing Address - Country:US
Mailing Address - Phone:702-281-6560
Mailing Address - Fax:
Practice Address - Street 1:5836 S PECOS RD
Practice Address - Street 2:BUILDING D SUITE 101
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89120-3418
Practice Address - Country:US
Practice Address - Phone:702-281-6560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20121132212251S00000X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No251S00000XAgenciesCommunity/Behavioral Health