Healthcare Provider Details

I. General information

NPI: 1811229602
Provider Name (Legal Business Name): CANYON GATE MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 02/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 N PECOS RD
HENDERSON NV
89074-1918
US

IV. Provider business mailing address

2929 N UNIVERSITY DR SUITE # 110
CORAL SPRINGS FL
33065-5081
US

V. Phone/Fax

Practice location:
  • Phone: 702-430-3570
  • Fax:
Mailing address:
  • Phone: 954-656-8855
  • Fax: 954-656-8856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12804
License Number StateNV

VIII. Authorized Official

Name: RICKI MOSKOW
Title or Position: PRESIDENT
Credential:
Phone: 954-656-8855