Healthcare Provider Details

I. General information

NPI: 1528844602
Provider Name (Legal Business Name): CHRISTIAN JOSE FERNANDEZ MEDINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 S MARYLAND PKWY STE 200
LAS VEGAS NV
89109-1554
US

IV. Provider business mailing address

9599 W CHARLESTON BLVD APT 2161
LAS VEGAS NV
89117-6678
US

V. Phone/Fax

Practice location:
  • Phone: 702-478-9594
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberB01996
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: