Healthcare Provider Details

I. General information

NPI: 1093981672
Provider Name (Legal Business Name): DEPARTMENT OF VETERANS AFFAIRS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 NORTH LAS VEGAS BLVD. NELLIS AIR FORCE BASE
LAS VEGAS NV
89191-6601
US

IV. Provider business mailing address

164 WELLSPRING AVE
LAS VEGAS NV
89183-7616
US

V. Phone/Fax

Practice location:
  • Phone: 702-653-3172
  • Fax:
Mailing address:
  • Phone: 702-653-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License NumberRN 22304
License Number StateNV

VIII. Authorized Official

Name: MRS. MARIETTA A. CABILLO
Title or Position: NURSE CLINICAL COORDINATOR
Credential: MSN, RN, BC
Phone: 702-653-3172