Healthcare Provider Details

I. General information

NPI: 1295317659
Provider Name (Legal Business Name): STARK MEDICINE MCKAY KHURANA JEIDER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 S RANCHO DR STE 4-903
LAS VEGAS NV
89106-3837
US

IV. Provider business mailing address

840 S RANCHO DR STE 4-903
LAS VEGAS NV
89106-3837
US

V. Phone/Fax

Practice location:
  • Phone: 702-440-8840
  • Fax: 866-518-0781
Mailing address:
  • Phone: 702-440-8840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TIMOTHY BENJAMIN JAMES JEIDER
Title or Position: OWNER
Credential:
Phone: 702-440-8430