Provider Demographics
NPI:1477093656
Name:POLLARD, PRINCE
Entity type:Individual
Prefix:
First Name:PRINCE
Middle Name:
Last Name:POLLARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 AIRMOTIVE WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3240
Mailing Address - Country:US
Mailing Address - Phone:928-529-8197
Mailing Address - Fax:
Practice Address - Street 1:3365 WEST CRAIG ROAD SUITE 9
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031
Practice Address - Country:US
Practice Address - Phone:775-357-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1404750365251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1404750365Medicaid