Healthcare Provider Details

I. General information

NPI: 1023663572
Provider Name (Legal Business Name): PHASE 1 MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2019
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7770 DEAN MARTIN DR STE 307
LAS VEGAS NV
89139-6603
US

IV. Provider business mailing address

7770 DEAN MARTIN DR STE 307
LAS VEGAS NV
89139-6603
US

V. Phone/Fax

Practice location:
  • Phone: 702-641-0011
  • Fax:
Mailing address:
  • Phone: 702-641-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. MICHAEL WATERS
Title or Position: OWNER
Credential:
Phone: 702-300-4880