Healthcare Provider Details

I. General information

NPI: 1275183766
Provider Name (Legal Business Name): NOT APPLICABLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 10/11/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 HAMILTON LN
LAS VEGAS NV
89106-4033
US

IV. Provider business mailing address

1820 FEATHERBROOK AVE
NORTH LAS VEGAS NV
89031-5052
US

V. Phone/Fax

Practice location:
  • Phone: 702-900-1489
  • Fax:
Mailing address:
  • Phone: 702-900-1489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YVETTE JONES
Title or Position: OFFICE MANAGER
Credential:
Phone: 702-350-1060