Healthcare Provider Details

I. General information

NPI: 1023508843
Provider Name (Legal Business Name): CLARK COUNTY MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 09/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2225 E FLAMINGO RD STE 100
LAS VEGAS NV
89119-5126
US

IV. Provider business mailing address

3650 S EASTERN AVE STE 330
LAS VEGAS NV
89169-3345
US

V. Phone/Fax

Practice location:
  • Phone: 702-831-8993
  • Fax: 702-922-0404
Mailing address:
  • Phone: 702-831-8993
  • Fax: 702-922-0404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0812X
TaxonomyCommunity Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNV
# 5
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNV

VIII. Authorized Official

Name: FERDINAND DALOPE
Title or Position: CEO
Credential:
Phone: 702-831-8993