Healthcare Provider Details

I. General information

NPI: 1417154188
Provider Name (Legal Business Name): PORFERIA MONTESCLAROS MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 N GREEN VALLEY PKWY BLDG 3 SUITE 312
HENDERSON NV
89014-0406
US

IV. Provider business mailing address

2920 N GREEN VALLEY PKWY BLDG 3 SUITE 312
HENDERSON NV
89014-0406
US

V. Phone/Fax

Practice location:
  • Phone: 702-253-1173
  • Fax: 702-253-1468
Mailing address:
  • Phone: 702-253-1173
  • Fax: 702-253-1468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11575
License Number StateNV

VIII. Authorized Official

Name: DR. PORFERIA D MONTESCLAROS
Title or Position: OWNER
Credential: MD
Phone: 702-253-1173