Provider Demographics
NPI:1205268695
Name:EXDOUS FAMILY & GUIDANCE COALITION LLC
Entity type:Organization
Organization Name:EXDOUS FAMILY & GUIDANCE COALITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PART OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:PILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-569-4455
Mailing Address - Street 1:1415 S MARYLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89104-3311
Mailing Address - Country:US
Mailing Address - Phone:702-569-4455
Mailing Address - Fax:
Practice Address - Street 1:1415 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3311
Practice Address - Country:US
Practice Address - Phone:702-569-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20131436018305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service