Provider Demographics
NPI:1811310584
Name:EXODUS FAMILY & GUIDANCE COALITION, LLC
Entity type:Organization
Organization Name:EXODUS FAMILY & GUIDANCE COALITION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:DELCINA
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:702-466-4360
Mailing Address - Street 1:9110 W LONE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-3563
Mailing Address - Country:US
Mailing Address - Phone:702-466-4360
Mailing Address - Fax:
Practice Address - Street 1:1415 S MARYLAND PKWY
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89104-3311
Practice Address - Country:US
Practice Address - Phone:702-466-4360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV193400000XMedicaid