Healthcare Provider Details

I. General information

NPI: 1376266833
Provider Name (Legal Business Name): ALTA MEDICAL CLINIC INC OF NEVADA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E TROPICANA AVE STE 163
LAS VEGAS NV
89119-6516
US

IV. Provider business mailing address

1500 E TROPICANA AVE STE 163
LAS VEGAS NV
89119-6516
US

V. Phone/Fax

Practice location:
  • Phone: 626-705-1005
  • Fax:
Mailing address:
  • Phone: 626-705-1005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084B0040X
TaxonomyBehavioral Neurology & Neuropsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: GLADELYNN ADLAO
Title or Position: VICE PRESIDENT
Credential: APRN
Phone: 626-705-1005