Healthcare Provider Details

I. General information

NPI: 1124385976
Provider Name (Legal Business Name): CHANWELL MEDICAL GROUP NEVADA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2012
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2749 SUNRIDGE HEIGHTS PKWY
HENDERSON NV
89052-5044
US

IV. Provider business mailing address

3726 LAS VEGAS BLVD S UNIT 3501W
LAS VEGAS NV
89158-4399
US

V. Phone/Fax

Practice location:
  • Phone: 702-568-0686
  • Fax: 702-568-0687
Mailing address:
  • Phone: 408-828-2283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number042535
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number42535
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License NumberA35593
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number042535
License Number StateCA

VIII. Authorized Official

Name: DR. ANTHONY QUAN CHAN
Title or Position: PRESIDENT
Credential: M.D
Phone: 702-568-0686