Healthcare Provider Details

I. General information

NPI: 1326707076
Provider Name (Legal Business Name): BEDUYA-PRINCER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2021
Last Update Date: 12/09/2021
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8565 S EASTERN AVE STE 150
LAS VEGAS NV
89123-2906
US

IV. Provider business mailing address

8565 S EASTERN AVE STE 150
LAS VEGAS NV
89123-2906
US

V. Phone/Fax

Practice location:
  • Phone: 702-902-0225
  • Fax:
Mailing address:
  • Phone: 702-902-0225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA TESSIE BEDUYA-PRINCER
Title or Position: CEO
Credential:
Phone: 702-902-0225