Healthcare Provider Details

I. General information

NPI: 1609536010
Provider Name (Legal Business Name): MODERN GENTLEMEN MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8432 RAVENCREST ST
LAS VEGAS NV
89139-6874
US

IV. Provider business mailing address

PO BOX 1992
YUMA AZ
85366-2391
US

V. Phone/Fax

Practice location:
  • Phone: 206-551-0154
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL MINCKLER
Title or Position: OWNER
Credential: MD
Phone: 833-436-8633