Healthcare Provider Details

I. General information

NPI: 1639720105
Provider Name (Legal Business Name): INTERCITY MEDICAL AND CONSULTING RESOURCES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 09/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W FLAMINGO RD
LAS VEGAS NV
89103-3924
US

IV. Provider business mailing address

848 N RAINBOW BLVD # 1508
LAS VEGAS NV
89107-1103
US

V. Phone/Fax

Practice location:
  • Phone: 888-354-2758
  • Fax:
Mailing address:
  • Phone: 888-354-2758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ELIAS LU
Title or Position: MANAGER
Credential:
Phone: 888-354-2758