Provider Demographics
NPI:1952674806
Name:KEKOA INC
Entity Type:Organization
Organization Name:KEKOA INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-513-8321
Mailing Address - Street 1:7345 FALCON ROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-1470
Mailing Address - Country:US
Mailing Address - Phone:702-513-8321
Mailing Address - Fax:
Practice Address - Street 1:7345 FALCON ROCK DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-1470
Practice Address - Country:US
Practice Address - Phone:702-513-8321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1679797633Medicaid
NV1053417345Medicaid
NV1487953915Medicaid
NV1366741183Medicaid
NV1164739017Medicaid
NV1740597715Medicaid