Healthcare Provider Details

I. General information

NPI: 1053528828
Provider Name (Legal Business Name): PACIFIC PEDORTHIC SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 S JONES BLVD
LAS VEGAS NV
89107-2614
US

IV. Provider business mailing address

106 S JONES BLVD
LAS VEGAS NV
89107-2614
US

V. Phone/Fax

Practice location:
  • Phone: 702-629-6818
  • Fax: 702-993-8426
Mailing address:
  • Phone: 702-629-6818
  • Fax: 702-993-8426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: NATHAN HIGHAM
Title or Position: PRESIDENT
Credential: CPED
Phone: 702-629-6818