Provider Demographics
NPI:1306936653
Name:STATE OF NEVADA
Entity type:Organization
Organization Name:STATE OF NEVADA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGENCY MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDSON-ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-486-4400
Mailing Address - Street 1:ATTN: CYNDI SMITH
Mailing Address - Street 2:240 S. HUMAHUACA
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048-2199
Mailing Address - Country:US
Mailing Address - Phone:775-751-7406
Mailing Address - Fax:775-751-7406
Practice Address - Street 1:1825 PINION RD
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-8355
Practice Address - Country:US
Practice Address - Phone:775-738-8021
Practice Address - Fax:775-782-8842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-14
Last Update Date:2022-11-10
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
NVVWQBGFMedicare PIN