Healthcare Provider Details

I. General information

NPI: 1073523221
Provider Name (Legal Business Name): VA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 W. OWENS AVE. LAS VEGAS NV 89036
LAS VEGAS NV
89117
US

IV. Provider business mailing address

2131 AMERICAS CUP CIR
LAS VEGAS NV
89117-1925
US

V. Phone/Fax

Practice location:
  • Phone: 702-636-3000
  • Fax:
Mailing address:
  • Phone: 702-324-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number5494
License Number StateNV

VIII. Authorized Official

Name: PROF. MOJTABA R MOTLAGH
Title or Position: PSYCHIATIST
Credential: MD
Phone: 70263630000