Provider Demographics
NPI:1750908828
Name:UNLV PRACTICE
Entity type:Organization
Organization Name:UNLV PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:MARY
Authorized Official - Last Name:PRENDERGAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-895-1564
Mailing Address - Street 1:4505 S MARYLAND PKWY
Mailing Address - Street 2:BOX 453033
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89154-9900
Mailing Address - Country:US
Mailing Address - Phone:702-895-1564
Mailing Address - Fax:702-895-1530
Practice Address - Street 1:4505 S MARYLAND PKWY
Practice Address - Street 2:CEB 226
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89154
Practice Address - Country:US
Practice Address - Phone:702-895-1564
Practice Address - Fax:702-895-1530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF NEVADA LAS VEGAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)