Healthcare Provider Details

I. General information

NPI: 1548085491
Provider Name (Legal Business Name): 702 FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3468 E SAHARA AVE STE 160
LAS VEGAS NV
89104-4827
US

IV. Provider business mailing address

3468 E SAHARA AVE STE 160
LAS VEGAS NV
89104-4827
US

V. Phone/Fax

Practice location:
  • Phone: 702-389-5700
  • Fax:
Mailing address:
  • Phone: 702-389-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: IREDILA TIMAGOS BYNUM
Title or Position: OWNER
Credential:
Phone: 702-389-5700