Healthcare Provider Details

I. General information

NPI: 1013755362
Provider Name (Legal Business Name): CHARLESTON CHUA MD MEDICAL SPA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4270 S DECATUR BLVD STE A1
LAS VEGAS NV
89103-6801
US

IV. Provider business mailing address

4270 S DECATUR BLVD STE B1B
LAS VEGAS NV
89103-6802
US

V. Phone/Fax

Practice location:
  • Phone: 725-529-2482
  • Fax: 725-215-9015
Mailing address:
  • Phone: 725-529-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CHARLESTON CHUA
Title or Position: OWNER
Credential: MD
Phone: 702-460-6009