Healthcare Provider Details

I. General information

NPI: 1417374968
Provider Name (Legal Business Name): SOUTHERN NEVADA MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2014
Last Update Date: 03/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 E FLAMINGO RD
LAS VEGAS NV
89119-5256
US

IV. Provider business mailing address

1485 E FLAMINGO RD
LAS VEGAS NV
89119-5256
US

V. Phone/Fax

Practice location:
  • Phone: 702-386-0882
  • Fax: 702-386-0977
Mailing address:
  • Phone: 702-386-0882
  • Fax: 702-386-0977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number1172
License Number StateNV

VIII. Authorized Official

Name: MICHELLE HYLA
Title or Position: OWNER
Credential: D.O.
Phone: 702-386-0882