Healthcare Provider Details

I. General information

NPI: 1265808190
Provider Name (Legal Business Name): ELSUBE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2015
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4132 SOLAR SYSTEM ST.
NORT LAS VEGAS NV
89032-0753
US

IV. Provider business mailing address

417 FOXVALE AVE.
NORTH LAS VEGAS NV
89032-6150
US

V. Phone/Fax

Practice location:
  • Phone: 702-619-1859
  • Fax: 702-463-0104
Mailing address:
  • Phone: 702-643-1552
  • Fax: 702-463-0104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number20121700531
License Number StateNV

VIII. Authorized Official

Name: MRS. ELODIA MAYNARD
Title or Position: MANAGER
Credential:
Phone: 702-643-1552