Provider Demographics
NPI:1962864439
Name:DUNGARVIN NEVADA, LLC - LAS VEGAS
Entity Type:Organization
Organization Name:DUNGARVIN NEVADA, LLC - LAS VEGAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:KRESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-699-0206
Mailing Address - Street 1:1444 NORTHLAND DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MENDOTA HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55120-1032
Mailing Address - Country:US
Mailing Address - Phone:651-699-0206
Mailing Address - Fax:651-699-0799
Practice Address - Street 1:3325 W CRAIG RD STE A
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-5002
Practice Address - Country:US
Practice Address - Phone:702-222-2243
Practice Address - Fax:702-222-0174
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DUNGARVIN GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-24
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005047616Medicaid