Healthcare Provider Details

I. General information

NPI: 1558429720
Provider Name (Legal Business Name): LAS VEGAS CLINIC FOR CHILDREN & YOUTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 7TH STREET
LAS VEGAS NM
87701
US

IV. Provider business mailing address

501 7TH STREET
LAS VEGAS NM
87701
US

V. Phone/Fax

Practice location:
  • Phone: 505-425-3566
  • Fax: 505-425-3568
Mailing address:
  • Phone: 505-425-3566
  • Fax: 505-425-3568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GEORGE P BUNCH
Title or Position: PRESIDENT MD
Credential: MD
Phone: 505-425-3566