Healthcare Provider Details

I. General information

NPI: 1134628480
Provider Name (Legal Business Name): BACCHUS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2018
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 SEVEN HILLS DR STE 140
HENDERSON NV
89052-4372
US

IV. Provider business mailing address

2370 CORPORATE CIR STE 300
HENDERSON NV
89074-7760
US

V. Phone/Fax

Practice location:
  • Phone: 702-844-4840
  • Fax: 702-844-4843
Mailing address:
  • Phone: 702-910-3950
  • Fax: 702-786-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BEVERLY DENDARY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 702-910-3950