Provider Demographics
NPI:1902230089
Name:ACADEMICS & ATHLETICS CONNECTION/LVSTARS, INC.
Entity Type:Organization
Organization Name:ACADEMICS & ATHLETICS CONNECTION/LVSTARS, INC.
Other - Org Name:ACADEMICS AND ATHLETICS CONNECTION BEHAVIORAL HEALTH PROGRAM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:MCTYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-834-0794
Mailing Address - Street 1:1324 ROBIN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1324 ROBIN ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1951
Practice Address - Country:US
Practice Address - Phone:702-834-0794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACADEMICS AND ATHLETICS CONNECTION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1093016727Medicaid