Healthcare Provider Details

I. General information

NPI: 1225763394
Provider Name (Legal Business Name): GOLDEN VICTORY MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 07/21/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2870 S MARYLAND PKWY STE 200
LAS VEGAS NV
89109-1580
US

IV. Provider business mailing address

2870 S MARYLAND PKWY STE 200
LAS VEGAS NV
89109-1580
US

V. Phone/Fax

Practice location:
  • Phone: 702-703-1950
  • Fax:
Mailing address:
  • Phone: 702-703-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: ELIZABETH BROWN
Title or Position: APRN/OWNER
Credential: APRN
Phone: 952-923-7256