Healthcare Provider Details

I. General information

NPI: 1366213183
Provider Name (Legal Business Name): COLCHIS MEDICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2024
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111B S GOVERNORS AVE STE 25428
DOVER DE
19904-6903
US

IV. Provider business mailing address

1980 FESTIVAL PLAZA DR STE 400
LAS VEGAS NV
89135-2930
US

V. Phone/Fax

Practice location:
  • Phone: 909-787-2342
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: STEVEN PEACOCK
Title or Position: PRESIDENT
Credential: DO
Phone: 909-787-2342