Provider Demographics
NPI:1174895890
Name:SUPER YOUTH OF NEVADA
Entity type:Organization
Organization Name:SUPER YOUTH OF NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:JEMIL
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-748-1508
Mailing Address - Street 1:867 WORRELL AVE.
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-3183
Mailing Address - Country:US
Mailing Address - Phone:702-748-1508
Mailing Address - Fax:
Practice Address - Street 1:867 WORRELL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-3183
Practice Address - Country:US
Practice Address - Phone:702-748-1508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-27
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty