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4170 S Decatur Blvd Ste C1 Las Vegas NV 89103-5863 | |
| (702) 659-8827 | |
| (702) 852-0984 |
| Full Name | |
|---|---|
| Speciality | Social Worker |
| Location | 4170 S Decatur Blvd Ste C1, Las Vegas, Nevada |
| Authorized Official Name and Position | Marysol Rezanov (OWNER) |
| Authorized Official Contact | 7026598827 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4170 S Decatur Blvd Ste C1 Las Vegas NV 89103-5863 Ph: (702) 659-8827 | 4170 S Decatur Blvd Ste C1 Las Vegas NV 89103-5863 Ph: (702) 659-8827 |
| NPI Number | 1598015240 |
|---|---|
| Provider Enumeration Date | 09/10/2012 |
| Last Update Date | 10/16/2017 |
| Medicare PECOS PAC ID | 3678702701 |
|---|---|
| Medicare Enrollment ID | O20140212000603 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1598015240 | NPI | - | NPPES |
| 1407281561 | Medicaid | NV | |
| 1003127499 | Other | NV | INDIVIDUAL NPI |
| 1225338361 | Medicaid | NV | |
| 1003116146 | Medicaid | NV | |
| 1497120059 | Medicaid | NV | |
| 1891867107 | Medicaid | NV | |
| 1982056172 | Medicaid | NV |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | 6215-C (Nevada) | Primary |
| Provider Name | Carol S Kohn-mannis |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1649457680 PECOS PAC ID: 8426048562 Enrollment ID: I20040512001272 |
| Provider Name | Marysol Rezanov |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1003127499 PECOS PAC ID: 7911136056 Enrollment ID: I20140212000729 |
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