Provider Demographics
NPI:1831587906
Name:IDA'S HOUSE
Entity type:Organization
Organization Name:IDA'S HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-612-6787
Mailing Address - Street 1:8665 W FLAMINGO RD
Mailing Address - Street 2:STE # 131
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-8621
Mailing Address - Country:US
Mailing Address - Phone:702-612-6787
Mailing Address - Fax:
Practice Address - Street 1:4022 ALLYSON RAE ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-0258
Practice Address - Country:US
Practice Address - Phone:702-612-6787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization