Healthcare Provider Details

I. General information

NPI: 1104738368
Provider Name (Legal Business Name): UNLV MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 E CHARLESTON BLVD STE 130
LAS VEGAS NV
89104-6681
US

IV. Provider business mailing address

4000 E CHARLESTON BLVD STE 130
LAS VEGAS NV
89104-6681
US

V. Phone/Fax

Practice location:
  • Phone: 702-968-4000
  • Fax:
Mailing address:
  • Phone: 702-968-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANA GIBSON
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 702-780-2314