Healthcare Provider Details

I. General information

NPI: 1487400099
Provider Name (Legal Business Name): PHENIX CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9222 SNOW FLOWER AVE
LAS VEGAS NV
89147-6843
US

IV. Provider business mailing address

9222 SNOW FLOWER AVE
LAS VEGAS NV
89147-6843
US

V. Phone/Fax

Practice location:
  • Phone: 702-624-6292
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ELIEZER LEON CUELLAR
Title or Position: MANAGER
Credential:
Phone: 702-515-9926