Healthcare Provider Details

I. General information

NPI: 1083919328
Provider Name (Legal Business Name): DIVERSIFIED COALITION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2011
Last Update Date: 01/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2340 PASEO DEL PRADO BUILDING D SUITE 206
LAS VEGAS NV
89102-4360
US

IV. Provider business mailing address

2340 PASEO DEL PRADO BUILDING D SUITE 206
LAS VEGAS NV
89102-4360
US

V. Phone/Fax

Practice location:
  • Phone: 702-485-2121
  • Fax:
Mailing address:
  • Phone: 702-485-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNV

VIII. Authorized Official

Name: MS. MYRNA T PILI
Title or Position: AUTHORIZED AGENT
Credential: MBA
Phone: 702-569-4455