Provider Demographics
NPI:1972940831
Name:NEW VANATGE LLC
Entity Type:Organization
Organization Name:NEW VANATGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATHANIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHBOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-212-6733
Mailing Address - Street 1:9781 DOTTIE JEWEL AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-6766
Mailing Address - Country:US
Mailing Address - Phone:313-212-6733
Mailing Address - Fax:
Practice Address - Street 1:9781 DOTTIE JEWEL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147-6766
Practice Address - Country:US
Practice Address - Phone:313-212-6733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-31
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1295098788Medicaid
NV1699872614Medicaid
NV1124383880Medicaid
NV1336492701Medicaid
NV1669735247Medicaid