Healthcare Provider Details

I. General information

NPI: 1841769429
Provider Name (Legal Business Name): CHARLESTON RESIDENTIAL MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 W CHARLESTON BLVD
LAS VEGAS NV
89102-2205
US

IV. Provider business mailing address

2121 W CHARLESTON BLVD
LAS VEGAS NV
89102-2205
US

V. Phone/Fax

Practice location:
  • Phone: 702-382-7746
  • Fax:
Mailing address:
  • Phone: 702-382-7746
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LYNN MORSS
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 702-332-3228