Healthcare Provider Details

I. General information

NPI: 1619394251
Provider Name (Legal Business Name): SAFE HARBOR MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2014
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 N TENAYA WAY STE 100
LAS VEGAS NV
89128-1404
US

IV. Provider business mailing address

2901 N TENAYA WAY STE 100
LAS VEGAS NV
89128-1404
US

V. Phone/Fax

Practice location:
  • Phone: 702-870-8852
  • Fax: 702-870-8914
Mailing address:
  • Phone: 702-870-8852
  • Fax: 702-870-8914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number380
License Number StateNV

VIII. Authorized Official

Name: TINA A ALICEA
Title or Position: CEO
Credential:
Phone: 702-870-8852