Healthcare Provider Details

I. General information

NPI: 1922422393
Provider Name (Legal Business Name): DESERT PODIATRY MANAGEMENT INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10624 S EASTERN AVE SUITEA #423
HENDERSON NV
89052-2982
US

IV. Provider business mailing address

1404 S DECATUR BLVD
LAS VEGAS NV
89102-8511
US

V. Phone/Fax

Practice location:
  • Phone: 702-480-1544
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0205
License Number StateNV

VIII. Authorized Official

Name: LANCE EISNER
Title or Position: PRESIDENT
Credential:
Phone: 702-480-1544