Healthcare Provider Details

I. General information

NPI: 1073721361
Provider Name (Legal Business Name): COMMUNITY OUTREACH MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 E DESERT INN RD STE 200
LAS VEGAS NV
89109-2803
US

IV. Provider business mailing address

1090 E DESERT INN RD STE 200
LAS VEGAS NV
89109-2803
US

V. Phone/Fax

Practice location:
  • Phone: 702-657-3873
  • Fax: 702-636-0787
Mailing address:
  • Phone: 702-657-3873
  • Fax: 702-636-0787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number8907
License Number StateNV

VIII. Authorized Official

Name: MRS. KEMA OGDEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 702-657-3873