Healthcare Provider Details

I. General information

NPI: 1083678486
Provider Name (Legal Business Name): CONSULTING INTERVENTIONAL CARDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 S WATER ST #108
HENDERSON NV
89015-2312
US

IV. Provider business mailing address

PO BOX 4398
MODESTO CA
95352-4398
US

V. Phone/Fax

Practice location:
  • Phone: 702-386-6855
  • Fax: 209-575-4598
Mailing address:
  • Phone: 209-575-4575
  • Fax: 209-575-4598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberF6379
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number17530
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number5498
License Number StateNV

VIII. Authorized Official

Name: JOHN ADAN
Title or Position: MANAGING GENERAL PARTNER
Credential: MD
Phone: 702-386-6855