Provider Demographics
NPI:1154614105
Name:MY HOME ICE
Entity type:Organization
Organization Name:MY HOME ICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ROBIN
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-595-2868
Mailing Address - Street 1:10880 DEODAR WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89506-9064
Mailing Address - Country:US
Mailing Address - Phone:775-786-4168
Mailing Address - Fax:775-786-5622
Practice Address - Street 1:10880 DEODAR WAY
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89506-9064
Practice Address - Country:US
Practice Address - Phone:775-786-4168
Practice Address - Fax:775-786-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005042666Medicaid
NV9005052384Medicare Oscar/Certification