MEDICARE: GREAT LIFE MEDICAL CENTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1487351854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LIFE MEDICAL CENTER LLC

Provider Business Mailing Address
First Line	:	1579 FALLING LEAF LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-1100
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1579 FALLING LEAF LN
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89142-1100
Country	:	US
Telephone Number	:	702-596-6451
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	IROSBEL REYES - BLANCO
Credential	:
Telephone Number	:	702-596-6451

Provider Enumeration Date	:	02/15/2023
Last Update Date	:	02/15/2023

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Directions to “GREAT LIFE MEDICAL CENTER LLC ” Practice Location

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