Healthcare Provider Details

I. General information

NPI: 1558153106
Provider Name (Legal Business Name): INTERMOUNTAIN MEDICAL HOLDING NEVADA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 LA CANADA ST STE 230
LAS VEGAS NV
89169-2551
US

IV. Provider business mailing address

6355 S BUFFALO DR FL 3
LAS VEGAS NV
89113-2133
US

V. Phone/Fax

Practice location:
  • Phone: 702-732-1290
  • Fax:
Mailing address:
  • Phone: 702-216-3346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MITCH CLOWARD
Title or Position: REGION PRESIDENT
Credential:
Phone: 702-216-3346