Provider Demographics
NPI:1992875157
Name:GOLLA HOME
Entity type:Organization
Organization Name:GOLLA HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MH TREATMENT HOME PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-849-3165
Mailing Address - Street 1:670 WASHOE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89704-9528
Mailing Address - Country:US
Mailing Address - Phone:775-849-3165
Mailing Address - Fax:775-849-9425
Practice Address - Street 1:670 WASHOE DR
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89704-9528
Practice Address - Country:US
Practice Address - Phone:775-849-3165
Practice Address - Fax:775-849-9425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100508067Medicaid
NV006116513Medicaid
NV100508066Medicaid