Healthcare Provider Details

I. General information

NPI: 1770085755
Provider Name (Legal Business Name): THERAPEUTIC INTEGRATED MEDICAL CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2018
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 S MARYLAND PKWY
LAS VEGAS NV
89109-2331
US

IV. Provider business mailing address

PO BOX 71526
LAS VEGAS NV
89170-1526
US

V. Phone/Fax

Practice location:
  • Phone: 702-617-6313
  • Fax:
Mailing address:
  • Phone: 702-617-6313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ROXANA VALETON
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 305-303-8108