Provider Demographics
NPI:1740370006
Name:STATE OF NEVADA
Entity type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:775-687-7500
Mailing Address - Street 1:4126 TECHNOLOGY WAY
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89706-2013
Mailing Address - Country:US
Mailing Address - Phone:775-687-7573
Mailing Address - Fax:775-687-7544
Practice Address - Street 1:3650 S POINTE CIR
Practice Address - Street 2:SUITE 208
Practice Address - City:LAUGHLIN
Practice Address - State:NV
Practice Address - Zip Code:89029-0424
Practice Address - Country:US
Practice Address - Phone:702-298-5313
Practice Address - Fax:702-298-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV30655Medicare PIN