Healthcare Provider Details

I. General information

NPI: 1871893016
Provider Name (Legal Business Name): GOLAN INTEGRATED PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2010
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6592 N. DECATUR BLVD SUITE # 115
LAS VEGAS NV
89131-1038
US

IV. Provider business mailing address

PO BOX 561564
DENVER CO
80256-1564
US

V. Phone/Fax

Practice location:
  • Phone: 702-396-4993
  • Fax: 702-636-4990
Mailing address:
  • Phone: 702-202-1850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberB00949
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License NumberB00949
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberB00949
License Number StateNV

VIII. Authorized Official

Name: JASON O JAEGER
Title or Position: OWNER
Credential: D.C.
Phone: 702-396-4993