Provider Demographics
NPI:1023324076
Name:MOUNTAIN INTERVAL, LLC
Entity type:Organization
Organization Name:MOUNTAIN INTERVAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:702-991-3150
Mailing Address - Street 1:4425 S JONES BLVD
Mailing Address - Street 2:SUITE # D3
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3370
Mailing Address - Country:US
Mailing Address - Phone:702-991-3150
Mailing Address - Fax:866-658-4052
Practice Address - Street 1:4425 S JONES BLVD
Practice Address - Street 2:SUITE D3
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3370
Practice Address - Country:US
Practice Address - Phone:702-991-3150
Practice Address - Fax:866-658-4052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-28
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health